Breast Cancer Survey

This survey is to help gather information about possible emotional connection to breast cancer.  Participants will remain anonymous and the data will be used for publication.  Thanks for your participation.

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* 1. What type of breast cancer were you originally diagnosed?

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* 2. Did the cancer spread?

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* 3. If yes where?

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* 4. Have you had a reoccurrence of cancer?

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* 5. If so what type?

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* 6. What year were you diagnosed?

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* 7. What age?

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* 8. Did you have cancer before breast cancer?

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* 9. If yes what type of cancer?

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* 10. What was your marital status at the time of diagnosis?

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* 11. Did you ever have fibrous breast?

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* 12. Did you ever suffer from breast tenderness?

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* 13. Were you placed on an estrogen blocker?

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* 14. Did you ever take birth control?

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* 15. If so what type?

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* 16. What was your age of your first menses?

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* 17. Did you ever have any breast surgery before cancer?

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* 18. If so what type of surgery

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* 19. What was happening in your life at the time of your diagnosis? ie stress, move, divorce, death, job loss

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* 20. Did you suffer from any female issues? ie mensural, endometriosis, infertility, miscarriage, hysterectomy

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* 21. Where you ever diagnosed with chronic fatigue?

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* 22. How many years did you have chronic fatigue?

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* 23. Have you ever suffered from allergies?

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* 24. Number of years that you suffered from allergies?

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* 25. Have you ever suffered from depression?

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* 26. If so how many years?

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* 27. Has anyone else in your family been diagnosed with breast cancer?

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* 28. If so whom?

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* 29. Have you ever had an abortion?

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* 30. If so how many?

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* 31. How many children do you have?

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* 32. Do you have step children?

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* 33. If so how many do you have?

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* 34. Do you have any children with special needs?

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* 35. Have you experienced a death of a child or a parent?

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* 36. If so whom?

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* 37. Are you a surrogate mom?

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* 38. Are you adoptive mom?

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* 39. How many full brothers or sisters do you have?

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* 40. How many half brothers or sisters do you have?

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* 41. What number child are you?

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* 42. Did you take on a parental role as a child?

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* 43. If so why?

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* 44. Do you have a sibling with special needs?

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* 45. If so what is there handicap?

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* 46. When you were a child did your Father work?

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* 47. When you were a child did you Mother work?

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* 48. When you were a child did you have a safe and nurturing relationship with your Mother?

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* 49. If not please explain. ie drugs, alcohol, abuse...

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* 50. Did you have a safe and nurturing relationship with your Father?

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* 51. If no please explain. ie drugs, alcohol, abuse.....

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* 52. Did you experience any childhood trauma?

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* 53. If so please explain. ie surgery, car accident, fire, adoption, death...

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* 54. Are you lactose intolerant?

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* 55. Do you suffer from digestive disorders?

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* 56. If so what type?

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* 57. How old were you when these stomach issues start to occur?

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* 58. Do you crave a certain taste?

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* 59. What are your favorite comfort foods or drinks?

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* 60. What is the one food you can 't give up or live without?

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* 61. When you are emotionally upset or stressed out what food or drink eases your pain?

Thank you for participating in this survey.  This information is being gathered for research for publication.  We appreciate you help.    

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* 62. May we contact you for any additional questions based on your survey?

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* 63. If yes please enter your contact information.

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