Metastatic Breast Cancer Symposium Survey

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* 1. Please tell us about YOU (select one or more).

I am a:

Metastatic Breast Cancer Patient

- Metastatic Cancer was my first diagnosis of this breast cancer

- Metastatic Breast Cancer was a recurrence of an earlier diagnosis

- I have included the date of my diagnosis in the comment box below

Family member or friend in a support role for a Mets Patient - add any details in comment box

Health care professional working with Mets Patients - add any details in comment box

Community health worker or other patient advocate supporting Mets Patients - add any details in comment box

Other - please explain in comment box

Other (please explain in comment section)

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* 2. What is your Zip Code? (Home for mets patients, work for service providers)

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* 3. Would you be interested in attending a Metastatic Breast Cancer Symposium in metro-Milwaukee? (Please select one or more)

In April 2018

In May 2018

Either in April or May

I am not available in those months

I am not able to travel to a symposium in metro-Milwaukee

I would not attend, but would watch a live streaming of the Symposium

I am not interested in attending

Additional comments

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* 4. What day(s) and time(s) of the week would be most convenient for you to attend a metro-Milwaukee Mets Symposium?

Monday - day time

Monday - evening

Tuesday - daytime

Tuesday - evening

Wednesday -daytime

Wednesday - evening

Thursday - daytime

Thursday - evening

Friday - daytime

Friday - evening

Saturday - daytime

Comments:

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* 5. I would prefer the symposium was (please select one or more)

A half day - morning

A half day - afternoon

A full day

A day and a half

Two days

No preference

Other Preferences

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* 6. Do you have any additional thoughts on the timing or the structure of a Metastatic Breast Cancer Symposium?

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* 7. Select your level of interest for each of the following Metastatic Breast Cancer topics:

	Very interested	Interested	Slightly interested	Neutral - indifferent	Not at all interested
Most current treatments	Most current treatments Very interested	Most current treatments Interested	Most current treatments Slightly interested	Most current treatments Neutral - indifferent	Most current treatments Not at all interested
Most current research	Most current research Very interested	Most current research Interested	Most current research Slightly interested	Most current research Neutral - indifferent	Most current research Not at all interested
Complementary or integrated therapies like yoga, acupuncture, massage, etc.	Complementary or integrated therapies like yoga, acupuncture, massage, etc. Very interested	Complementary or integrated therapies like yoga, acupuncture, massage, etc. Interested	Complementary or integrated therapies like yoga, acupuncture, massage, etc. Slightly interested	Complementary or integrated therapies like yoga, acupuncture, massage, etc. Neutral - indifferent	Complementary or integrated therapies like yoga, acupuncture, massage, etc. Not at all interested
Immunotherapies (treatments that helps your immune system fight cancer)	Immunotherapies (treatments that helps your immune system fight cancer) Very interested	Immunotherapies (treatments that helps your immune system fight cancer) Interested	Immunotherapies (treatments that helps your immune system fight cancer) Slightly interested	Immunotherapies (treatments that helps your immune system fight cancer) Neutral - indifferent	Immunotherapies (treatments that helps your immune system fight cancer) Not at all interested
Side effect management	Side effect management Very interested	Side effect management Interested	Side effect management Slightly interested	Side effect management Neutral - indifferent	Side effect management Not at all interested
Emotional support strategies	Emotional support strategies Very interested	Emotional support strategies Interested	Emotional support strategies Slightly interested	Emotional support strategies Neutral - indifferent	Emotional support strategies Not at all interested
Communication strategies with friends, families, co-workers	Communication strategies with friends, families, co-workers Very interested	Communication strategies with friends, families, co-workers Interested	Communication strategies with friends, families, co-workers Slightly interested	Communication strategies with friends, families, co-workers Neutral - indifferent	Communication strategies with friends, families, co-workers Not at all interested
Nutrition/Diet support strategies	Nutrition/Diet support strategies Very interested	Nutrition/Diet support strategies Interested	Nutrition/Diet support strategies Slightly interested	Nutrition/Diet support strategies Neutral - indifferent	Nutrition/Diet support strategies Not at all interested
Physical/body support strategies	Physical/body support strategies Very interested	Physical/body support strategies Interested	Physical/body support strategies Slightly interested	Physical/body support strategies Neutral - indifferent	Physical/body support strategies Not at all interested
Perspectives/viewpoints from current metastatic patients	Perspectives/viewpoints from current metastatic patients Very interested	Perspectives/viewpoints from current metastatic patients Interested	Perspectives/viewpoints from current metastatic patients Slightly interested	Perspectives/viewpoints from current metastatic patients Neutral - indifferent	Perspectives/viewpoints from current metastatic patients Not at all interested
Palliative care(symptom management, quality life issues) - what it is and how it is used	Palliative care(symptom management, quality life issues) - what it is and how it is used Very interested	Palliative care(symptom management, quality life issues) - what it is and how it is used Interested	Palliative care(symptom management, quality life issues) - what it is and how it is used Slightly interested	Palliative care(symptom management, quality life issues) - what it is and how it is used Neutral - indifferent	Palliative care(symptom management, quality life issues) - what it is and how it is used Not at all interested
Parenting issues	Parenting issues Very interested	Parenting issues Interested	Parenting issues Slightly interested	Parenting issues Neutral - indifferent	Parenting issues Not at all interested
Sexuality/Intimacy/Body Image issues	Sexuality/Intimacy/Body Image issues Very interested	Sexuality/Intimacy/Body Image issues Interested	Sexuality/Intimacy/Body Image issues Slightly interested	Sexuality/Intimacy/Body Image issues Neutral - indifferent	Sexuality/Intimacy/Body Image issues Not at all interested
Work and employment issues	Work and employment issues Very interested	Work and employment issues Interested	Work and employment issues Slightly interested	Work and employment issues Neutral - indifferent	Work and employment issues Not at all interested
Financial issues	Financial issues Very interested	Financial issues Interested	Financial issues Slightly interested	Financial issues Neutral - indifferent	Financial issues Not at all interested
Advocating for your own best care as a Mets patient	Advocating for your own best care as a Mets patient Very interested	Advocating for your own best care as a Mets patient Interested	Advocating for your own best care as a Mets patient Slightly interested	Advocating for your own best care as a Mets patient Neutral - indifferent	Advocating for your own best care as a Mets patient Not at all interested
Broader mets patient advocacy issues	Broader mets patient advocacy issues Very interested	Broader mets patient advocacy issues Interested	Broader mets patient advocacy issues Slightly interested	Broader mets patient advocacy issues Neutral - indifferent	Broader mets patient advocacy issues Not at all interested
Navigating (getting around) the health system	Navigating (getting around) the health system Very interested	Navigating (getting around) the health system Interested	Navigating (getting around) the health system Slightly interested	Navigating (getting around) the health system Neutral - indifferent	Navigating (getting around) the health system Not at all interested
Clinical trials on Metastatic Breast Cancer	Clinical trials on Metastatic Breast Cancer Very interested	Clinical trials on Metastatic Breast Cancer Interested	Clinical trials on Metastatic Breast Cancer Slightly interested	Clinical trials on Metastatic Breast Cancer Neutral - indifferent	Clinical trials on Metastatic Breast Cancer Not at all interested

Additional topics of interest or comments:

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* 8. Are there any National or local Metastatic Breast Cancer speakers you would like to see as presenters at the upcoming Symposium? (Please include names and any additional info you may have)

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* 9. Please provide us with your contact information: (optional)

This information will NOT be shared with others and will only be used to keep you informed about the upcoming Metastatic Breast Cancer Symposium.

Name

Email Address

Phone Number

If you prefer to not leave your contact information but would like to stay updated on a
2018 Metastatic Breast Cancer Symposium please contact Robin Luther at
robin@komenwisconsin.org or by phone at 414.389-4882.
Always feel free to be in touch with any questions, comments, or ideas.

Thank you for participating in this survey. Your input is much appreciated!

Question Title

* 1. Please tell us about YOU (select one or more).I am a:

Question Title

* 2. What is your Zip Code? (Home for mets patients, work for service providers)

Question Title

* 3. Would you be interested in attending a Metastatic Breast Cancer Symposium in metro-Milwaukee? (Please select one or more)

Question Title

* 4. What day(s) and time(s) of the week would be most convenient for you to attend a metro-Milwaukee Mets Symposium?

Question Title

* 5. I would prefer the symposium was (please select one or more)

Question Title

* 6. Do you have any additional thoughts on the timing or the structure of a Metastatic Breast Cancer Symposium?

Question Title

* 7. Select your level of interest for each of the following Metastatic Breast Cancer topics:

Question Title

* 8. Are there any National or local Metastatic Breast Cancer speakers you would like to see as presenters at the upcoming Symposium? (Please include names and any additional info you may have)

Question Title

* 9. Please provide us with your contact information: (optional)This information will NOT be shared with others and will only be used to keep you informed about the upcoming Metastatic Breast Cancer Symposium.

* 1. Please tell us about YOU (select one or more).

I am a:

* 9. Please provide us with your contact information: (optional)

This information will NOT be shared with others and will only be used to keep you informed about the upcoming Metastatic Breast Cancer Symposium.