MHNMEB2025: Cancer Patients and Caregivers

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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
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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.

Name: *

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address: *

Phone Number: *

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* 2. Gender?

Male

Female

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* 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+

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* 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:

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* 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	Heart disease Me	Heart disease Loved one	Heart disease Me and Loved one	Heart disease Neither
Depression	Depression Me	Depression Loved one	Depression Me and Loved one	Depression Neither
Cancer	Cancer Me	Cancer Loved one	Cancer Me and Loved one	Cancer Neither
Stroke	Stroke Me	Stroke Loved one	Stroke Me and Loved one	Stroke Neither
Alzheimer’s Disease	Alzheimer’s Disease Me	Alzheimer’s Disease Loved one	Alzheimer’s Disease Me and Loved one	Alzheimer’s Disease Neither
Afib (Atrial Fibrillation)	Afib (Atrial Fibrillation) Me	Afib (Atrial Fibrillation) Loved one	Afib (Atrial Fibrillation) Me and Loved one	Afib (Atrial Fibrillation) Neither
Lupus SLE	Lupus SLE Me	Lupus SLE Loved one	Lupus SLE Me and Loved one	Lupus SLE Neither
Lupus DLE	Lupus DLE Me	Lupus DLE Loved one	Lupus DLE Me and Loved one	Lupus DLE Neither
Chronic kidney disease	Chronic kidney disease Me	Chronic kidney disease Loved one	Chronic kidney disease Me and Loved one	Chronic kidney disease Neither

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* 6. What type of cancer have you or your loved one been diagnosed with?

	Me	Loved one	Neither
Non-Small Cell Lung cancer	Non-Small Cell Lung cancer Me	Non-Small Cell Lung cancer Loved one	Non-Small Cell Lung cancer Neither
Small Cell Lung Cancer	Small Cell Lung Cancer Me	Small Cell Lung Cancer Loved one	Small Cell Lung Cancer Neither
Breast cancer	Breast cancer Me	Breast cancer Loved one	Breast cancer Neither
Prostate cancer	Prostate cancer Me	Prostate cancer Loved one	Prostate cancer Neither
Skin cancer	Skin cancer Me	Skin cancer Loved one	Skin cancer Neither
Kidney cancer	Kidney cancer Me	Kidney cancer Loved one	Kidney cancer Neither
Head & Neck cancer	Head & Neck cancer Me	Head & Neck cancer Loved one	Head & Neck cancer Neither
Colorectal cancer	Colorectal cancer Me	Colorectal cancer Loved one	Colorectal cancer Neither
Pancreatic cancer	Pancreatic cancer Me	Pancreatic cancer Loved one	Pancreatic cancer Neither
Stomach cancer	Stomach cancer Me	Stomach cancer Loved one	Stomach cancer Neither
DLBCL - diffuse large b cell lymphoma	DLBCL - diffuse large b cell lymphoma Me	DLBCL - diffuse large b cell lymphoma Loved one	DLBCL - diffuse large b cell lymphoma Neither
Multiple myeloma	Multiple myeloma Me	Multiple myeloma Loved one	Multiple myeloma Neither
CLL - Chronic lymphocytic leukemia	CLL - Chronic lymphocytic leukemia Me	CLL - Chronic lymphocytic leukemia Loved one	CLL - Chronic lymphocytic leukemia Neither
None of the above	None of the above Me	None of the above Loved one	None of the above Neither

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* 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

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* 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

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* 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

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* 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

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* 11. What is your date of birth?

Date / Time

Date

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* 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	Coordinating care for their cancer treatment / management Rarely (less than 1 time a year) or Never	Coordinating care for their cancer treatment / management About 1 time a year	Coordinating care for their cancer treatment / management 2-3 times a year	Coordinating care for their cancer treatment / management 4-6 times a year	Coordinating care for their cancer treatment / management More than 6 times a year
Food preparation	Food preparation Rarely (less than 1 time a year) or Never	Food preparation About 1 time a year	Food preparation 2-3 times a year	Food preparation 4-6 times a year	Food preparation More than 6 times a year
Grocery shopping	Grocery shopping Rarely (less than 1 time a year) or Never	Grocery shopping About 1 time a year	Grocery shopping 2-3 times a year	Grocery shopping 4-6 times a year	Grocery shopping More than 6 times a year
Housework	Housework Rarely (less than 1 time a year) or Never	Housework About 1 time a year	Housework 2-3 times a year	Housework 4-6 times a year	Housework More than 6 times a year
Managing finances	Managing finances Rarely (less than 1 time a year) or Never	Managing finances About 1 time a year	Managing finances 2-3 times a year	Managing finances 4-6 times a year	Managing finances More than 6 times a year
Personal hygiene	Personal hygiene Rarely (less than 1 time a year) or Never	Personal hygiene About 1 time a year	Personal hygiene 2-3 times a year	Personal hygiene 4-6 times a year	Personal hygiene More than 6 times a year
Researching treatment option(s) for their cancer	Researching treatment option(s) for their cancer Rarely (less than 1 time a year) or Never	Researching treatment option(s) for their cancer About 1 time a year	Researching treatment option(s) for their cancer 2-3 times a year	Researching treatment option(s) for their cancer 4-6 times a year	Researching treatment option(s) for their cancer More than 6 times a year
Taking their medication	Taking their medication Rarely (less than 1 time a year) or Never	Taking their medication About 1 time a year	Taking their medication 2-3 times a year	Taking their medication 4-6 times a year	Taking their medication More than 6 times a year
Talking with their doctors	Talking with their doctors Rarely (less than 1 time a year) or Never	Talking with their doctors About 1 time a year	Talking with their doctors 2-3 times a year	Talking with their doctors 4-6 times a year	Talking with their doctors More than 6 times a year
Transportation	Transportation Rarely (less than 1 time a year) or Never	Transportation About 1 time a year	Transportation 2-3 times a year	Transportation 4-6 times a year	Transportation More than 6 times a year
Helping perform other medical care-related tasks	Helping perform other medical care-related tasks Rarely (less than 1 time a year) or Never	Helping perform other medical care-related tasks About 1 time a year	Helping perform other medical care-related tasks 2-3 times a year	Helping perform other medical care-related tasks 4-6 times a year	Helping perform other medical care-related tasks More than 6 times a year