Lung Cancer Questionnaire for Patients

Demographics

The following questions are designed to better understand your background.

Question Title

1. Where do you live?

New England (Connecticut, Maine, Massachusetts, Rhode Island, Vermont)

Mid-Atlantic (New Jersey, New York, Pennsylvania)

East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin)

West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota)

South Atlantic (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington DC, West Virginia)

East South Central (Alabama, Kentucky, Mississippi, Tennessee)

West South Central (Arkansas, Louisiana, Texas)

Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming)

Pacific (Alaska, California, Hawaii, Oregon, Washington)

Question Title

2. What is your age?

Younger than 30

31 – 40

41 – 50

51 – 60

61 – 70

71 or greater

Question Title

3. Are you

Male

Female

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4. What is your race? Choose all that apply

White

Black or African American

American Indian or Alaskan Native

Asian Indian

Asian

Pacific Islander

Question Title

5. Do you have insurance coverage?

Yes

Question Title

* 1. Where do you live?

Question Title

* 2. What is your age?

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* 3. Are you

Question Title

* 4. What is your race? Choose all that apply

Question Title

* 5. Do you have insurance coverage?

1. Where do you live?

2. What is your age?

3. Are you

4. What is your race? Choose all that apply

5. Do you have insurance coverage?