[ACT]IVATED Patient Plan

Thank you for taking the [ACT]IVATED assessment. Once complete, your custom patient plan featuring a collection of vetted resources will be emailed to you. Learn more about the ACTIVATED program here.

Thank you for taking this assessment. Your patient plan will be emailed to you within 5 minutes. If you don't see it, please be sure to check your spam. Stay [ACT]IVATED.

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* 1. What does it mean to be an ACTIVATED patient and/or care partner?

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* 2. Do you incorporate wellness activities into your daily routine?

Yes

Occasionally

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* 3. Do you experience any of the following treatment side effects?

Breathlessness and cough

Nausea/vomiting

Fatigue

Muscle pain

Difficulty swallowing

Chest discomfort or pain

Changes in bowel/bladder function

Flu-like symptoms

Digestive issues

Weight gain or loss

Hot flashes and mood changes

Hair loss

Mouth sores

Loss of appetite

Skin irritation or reactions

Scarring/discomfort at incision site

Allergic reactions

Muscle/bone pain or soreness

Diarrhea/constipation

Numbness and tingling in hands/feet

Hair loss

Skin changes

Heart damage

Trouble thinking

Infection/fever

Trouble breathing

Low blood counts

Urinary symptoms

Mouth sores

Not applicable

Other (please specify)

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* 4. What other resources will help you as you navigate your care?

Insurance information

Available treatment options

Emotional well-being

Social issues

Dating and cancer

Second opinions

Connecting to support groups

Clinical trials

General testing and biomarker testing

Financial toxicity

Patient stories

Nutrition information

Exercise tips

Care partners

Survivorship/Recurrence

I would like to share my journey with PEN

Other (please specify)

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* 5. Contact Information

Name

Email Address