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MHNMEB2025: Cancer Patients and Caregivers
1.
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1.
Murray Hill National, a market research company, will be in your area soon conducting PAID RESEARCH. We would like to invite you to receive notifications on all studies that might apply to you. All of our
research will pay you an incentive. Cash and / or Rewards. We will input your information into our
database and contact you if you meet specific criteria. To get started, we require, at a minimum,
your contact information. We are asking a host of questions that will assist us in narrowing down which
studies / research best meets your profile. We are excited to work with you.
(Required.)
Name:
*
Company:
Address:
Address 2:
City/Town:
State:
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
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IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
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MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
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MP Northern Mariana Islands
OH Ohio
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PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Country:
Email Address:
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Phone Number:
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2.
Gender?
Male
Female
3.
How young are you?
under 18
18-25
26-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
4.
What is your race or ethnicity?
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial or Multiethnic
Native American or Alaska Native
Native Hawaiian or other Pacific Islander
White
Another race or ethnicity, please describe below
Self-describe below:
5.
Have you or a loved one ever been diagnosed with any of the following conditions? Please select all that apply.
Me
Loved one
Me and Loved one
Neither
Heart disease
Me
Loved one
Me and Loved one
Neither
Depression
Me
Loved one
Me and Loved one
Neither
Cancer
Me
Loved one
Me and Loved one
Neither
Stroke
Me
Loved one
Me and Loved one
Neither
Alzheimer’s Disease
Me
Loved one
Me and Loved one
Neither
Afib (Atrial Fibrillation)
Me
Loved one
Me and Loved one
Neither
Lupus SLE
Me
Loved one
Me and Loved one
Neither
Lupus DLE
Me
Loved one
Me and Loved one
Neither
Chronic kidney disease
Me
Loved one
Me and Loved one
Neither
6.
What type of cancer have you or your loved one been diagnosed with?
Me
Loved one
Neither
Non-Small Cell Lung cancer
Me
Loved one
Neither
Small Cell Lung Cancer
Me
Loved one
Neither
Breast cancer
Me
Loved one
Neither
Prostate cancer
Me
Loved one
Neither
Skin cancer
Me
Loved one
Neither
Kidney cancer
Me
Loved one
Neither
Head & Neck cancer
Me
Loved one
Neither
Colorectal cancer
Me
Loved one
Neither
Pancreatic cancer
Me
Loved one
Neither
Stomach cancer
Me
Loved one
Neither
DLBCL - diffuse large b cell lymphoma
Me
Loved one
Neither
Multiple myeloma
Me
Loved one
Neither
CLL - Chronic lymphocytic leukemia
Me
Loved one
Neither
None of the above
Me
Loved one
Neither
7.
At what stage is you or your loved ones Non-small cell lung cancer?
Stage I – cancer is localized to one part of the body
Stage II – cancer is locally advanced
Stage IIIa – cancer is locally advanced or spread to a nearby part of the body (resectable)
Stage IIIb – cancer is locally advanced or spread to a nearby part of the body (non-resectable)
Stage IV – cancer has spread or metastasized to other parts of the body
8.
Were you or your loved one diagnosed with a mutated form of NSCLC?
EGFR mutant
ALK mutant
BRAF mutant
ROS1 mutant
Other mutation
No mutations
Not sure
9.
Which of the following subtypes of non-small cell lung cancer (NSCLC)
Squamous cell carcinoma
Adenocarcinoma (non-squamous cell carcinoma)
Other
Don’t Know / Not Sure
10.
Which of the following describes you or your loved one's current treatment status for the non-small cell lung cancer?
Currently receiving treatment, and this is the first treatment received for
Currently receiving treatment, and have previously received other treatment(s) for
Not currently on any treatment, but have been in the past
Not currently on any treatment, and have never been in the past
11.
What is your date of birth?
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
12.
How often, if ever, do you help your loved one with NSCLC with the following activities:
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Coordinating care for their cancer treatment / management
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Food preparation
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Grocery shopping
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Housework
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Managing finances
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Personal hygiene
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Researching treatment option(s) for their cancer
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Taking their medication
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Talking with their doctors
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Transportation
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
Helping perform other medical care-related tasks
Rarely (less than 1 time a year) or Never
About 1 time a year
2-3 times a year
4-6 times a year
More than 6 times a year
