Cancer Survivors - Survey of Needs

What Are your needs?

This survey of needs will provide awareness and insight into the needs of cancer survivors and provide leaders with valuable information needed to provide appropriate resources and plan supportive programs.  Whether you completed treatment ten days or ten years ago, or continue to receive treatment, it's important we hear from you. Please take a few moments to complete this survey and share your thoughts with us.  Thank you.

1.  Demographics

        Age:  ______                    Gender:     o Male        o Female

Ethnicity:            
           o African American/Black                           o Latino/Hispanic             o American Indian/Alaskan Native

            o Caucasian/White                                    o Asian                           o Pacific Islander

            o Other                                                                                                 o Unknown 

Year of cancer diagnosis __________   Type of cancer _______________                                                             

Type of treatment received (check all that apply)

            o Surgery                    o Radiation       o Chemotherapy    o Hormonal    o Other

Currently receiving treatment?   o Yes          o No

2.  Please circle the number (0-10) that describes your overall Quality of Life during the past week, including today:

      0          1          2          3          4          5          6          7          8          9          10 

      As bad as                                                                                                         As good as

      it can be                                                                                                          it can be

As a cancer survivor you may experience some lasting side effects from your treatment. Please rate each topic according to how much concern it is causing you today.

Please circle the number on the scale from 0 (no concerns) to 5 (extreme concerns).

3.   Physical Effects

	No concerns                                                  Extreme concerns
	0	1	2	3	4	5
Pain	0	1	2	3	4	5
Fatigue	0	1	2	3	4	5
Sleep disturbance	0	1	2	3	4	5
Memory and concentration	0	1	2	3	4	5
Nausea / Vomiting	0	1	2	3	4	5
Poor appetite	0	1	2	3	4	5
Trouble swallowing	0	1	2	3	4	5
Dental or mouth problems	0	1	2	3	4	5
Weight changes	0	1	2	3	4	5
Balance / Walking / Mobility	0	1	2	3	4	5
Loss of strength	0	1	2	3	4	5
Tingling or numbness in feet & hands (neuropathy)	0	1	2	3	4	5
Swelling in legs or arms (lymphedema)	0	1	2	3	4	5
Osteoporosis / Bone health	0	1	2	3	4	5
	No concerns                                                    Extreme concerns
Hair and skin care issues	0	1	2	3	4	5
Body changes	0	1	2	3	4	5
Bowel or bladder changes	0