Cancer Care Treatment Selection Survey
Help us understand your preferences and priorities regarding cancer treatment options.
Patient Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Type of Cancer Diagnosed
*
Please Select
Breast Cancer
Lung Cancer
Colorectal Cancer
Prostate Cancer
Leukemia
Lymphoma
Other
Stage of Cancer at Diagnosis
*
Stage 0
Stage I
Stage II
Stage III
Stage IV
Unknown
Please indicate the level of your current symptoms:
*
Rows
Pain
Fatigue
Nausea
Emotional Distress
None
1
2
3
4
Mild
5
6
7
8
Moderate
9
10
11
12
Severe
13
14
15
16
What are your primary goals for cancer treatment? (Select up to 2)
*
Cure the cancer
Prolong life
Improve quality of life
Reduce symptoms
Other
Which treatment options have you discussed or considered? (Select all that apply)
*
Surgery
Chemotherapy
Radiation therapy
Immunotherapy
Targeted therapy
Clinical trials
Palliative care
Other
How important are the following factors in your treatment decision?
*
Rows
Effectiveness of treatment
Side effects
Impact on daily life
Cost/insurance coverage
Travel distance to treatment center
Advice from healthcare team
Not important
17
18
19
20
21
22
Somewhat important
23
24
25
26
27
28
Important
29
30
31
32
33
34
Very important
35
36
37
38
39
40
Please rate your overall satisfaction with the information provided to you about treatment options.
*
1
2
3
4
5
Is there anything else you would like to share about your treatment preferences or concerns?
Submit Survey
Should be Empty: