1. Oral Health Needs Assessment for Cancer Patients

The purpose of the following survey is to assess the oral health needs of people living with cancer and to provide feedback about the OHCCP website.

This survey is voluntary and you may elect not to participate. Your completion of the survey, in whole or in part, indicates your willingness to participate and will serve as consent. There is no compensation for participating and there are no risks or benefits associated with completing the survey. Your answers are kept confidential and your responses will not be name linked to any summary information.

All collective information will exclusively be used for purposes of web development only.

* 1. Age

* 2. Sex

* 3. Location

* 4. Due to chemotherapy and/or radiation therapy, I have/have had the following conditions (please check all that apply):

* 5. Due to chemotherapy and/or radiation therapy, I need/have needed the following dental treatments (please check all that apply):