|
Sex
|
|
|
Race
|
|
|
Age at Diagnosis
|
|
|
Current Age
|
|
|
Highest Education Level
|
|
|
|
What is your relationship to the patient?
|
|
| Select a Health Care Provider
|
|
| Select a Physician
|
|
|
|
Have you (or the patient) ever been offered survivorship health information before?
|
Have you ever received a treatment summary?
|
|
Who is currently managing your healthcare needs?
|
If other, please specify:
|
|
What is your geographical location?
|
USA
Canada
Other Country
|
Where do you consider yourself living?
Urban (city)
Suburban (Near city)
Rural (Country side) |
Where have you received most of your cancer care?
University based cancer center
Non-university based hospital cancer center
Private doctor's office
Combination of these
|
How far do you live from the cancer center where you received most of your cancer treatment?
Less than 20 miles (32 kilometers)
Greater than 20 miles (32 kilometers) |
|
What is your menopausal status?
Menopause occurred before cancer therapy
Postmenopausal (defined as 12 consecutive months without a period)
due to surgery
due to chemotherapy or radiation therapy
Menopause occurred after cancer therapy, but not due to therapy
Premenopausal
Perimenopausal (this is the time of transition to menopause)
Not sure (recently completed therapy, unsure if periods will return)
|
Share
