DEFEATcancer Central Oregon Young Adult Survivors

Exit this survey

 

1. Please tell us about yourself

Please tell us about yourself   First Name:
Last Name:
Address:
Address:
City:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
Phone Number:
Email Address:
Age:

2. Tell us a little more about yourself

Tell us a little more about yourself   Employment Status:
Relationship Status:
Number of children:
Family Cancer History:

3. Please tell us about your cancer experience

Please tell us about your cancer experience   Cancer type
Age at cancer diagnosis
Children's ages at your diagnosis

4. Tell us about your cancer treatment

Tell us about your cancer treatment   Did you receive cancer treatment in Central Oregon?
If not, where were you treated?

5. Did your cancer teatment include:

Did your cancer teatment include:   surgery chemotherapy radiation

Other (please specify)

6. Have you participated in a cancer group?

Have you participated in a cancer group?   Support group DEFEATcancer

Other (please specify)

7. Would a group geared towards young adult cancer survivors be of interest to you?

Would a group geared towards young adult cancer survivors be of interest to you?   yes no I'd try it

8. Would you prefer (mark all that apply)

Would you prefer (mark all that apply)   Traditional support group based on sharing experiences Educational presentations Activity based group

Other ideas

9. To help us in planning meetings:

	Yes	No	See below
Do you have survivorship issues which you would like to see addressed?	*To help us in planning meetings: Do you have survivorship issues which you would like to see addressed? Yes	Do you have survivorship issues which you would like to see addressed? No	Do you have survivorship issues which you would like to see addressed? See below
Would you prefer to meet at the hospital?	Would you prefer to meet at the hospital? Yes	Would you prefer to meet at the hospital? No	Would you prefer to meet at the hospital? See below
Would you prefer to meet in a more casual setting(such as a coffee shop)?	Would you prefer to meet in a more casual setting(such as a coffee shop)? Yes	Would you prefer to meet in a more casual setting(such as a coffee shop)? No	Would you prefer to meet in a more casual setting(such as a coffee shop)? See below

Please comment on locations and/or meeting topics

10. Any additional ideas or comments?

Any additional ideas or comments?