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Report a Diagnosis
FAQs
Cancer CARE for Life
Clients
Employers
Health Plans
Life Insurance
Refer a Patient
Services
Prevention & Early Detection
Pre-Treatment Planning
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Survivors
Survivors
Getting Started
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Spotlight
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Survivors Survey
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Survivors
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Survivors Survey
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Step
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Thank you for sharing your experiences with us. As a cancer survivor, your voice matters. The information you provide will help us understand your needs, improve the support we offer, and ensure you receive the best care possible. Your responses are private and will only be used to guide care and resources. By completing this survey, you are helping us learn how to better support your health, we’ll-being, and journey after treatment.
Name
First
Last
Age
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Date of Diagnosis
Type of Cancer
Treatment(s) Received:
Surgery
Chemotherapy
Radiation
Immunotherapy
Hormonal Therapy
Other
Describe other treatment(s) received
Date of treatment completion
Next
Do you have a follow-up care plan provided by your oncology team?
Yes
No
Not Sure
Have you had any of the following in the past 12 months? (Check all that apply)
Routine physical exam
Cancer-specific surveillance tests (e.g. mammogram, colonoscopy)
Blood work or imaging ordered by oncology team
of designated Have
Are you aware of signs/symptoms to monitor for possible recurrence?
Yes
No
Previous
Next
Are you experiencing any of the following symptoms? (Check all that apply)
Fatigue
Pain
Neuropathy (numbness/tingling)
Swelling (e.g. lymphedema)
Cognitive difficulties ("chemo brain")
Sexual dysfunction
Menopausal symptoms
Heart or lung problems
Osteoporosis or bone issues
Weight changes
Have you received counseling or treatment for these symptoms?
Yes
No
If yes, please specify.
Previous
Next
In the past month, have you felt depressed?
Not at all
Sometimes
Often
In the past month, have you felt anxious or fearful of recurrence?
Not at all
Sometimes
Often
Have you had access to a mental heath provider or counselor?
Yes
No
Have you had access to a support group?
Yes
No
Do you feel socially supported by family/friends/community?
Yes
No
Somewhat
Previous
Next
Do you engage in regular physical activity?
Yes
No
Do you follow a healthy diet?
Yes
No
Do you use tobacco products?
Yes
No
Do you consume alcohol?
Yes
No
Socially
Daily
Excessively
Have you received guidance on nutrition?
Yes
No
Have you received guidance on physical activity?
Yes
No
Have you received guidance on weight management?
Yes
No
Previous
Next
Do you have a designated primary care provider (PCP)?
Yes
No
Has your oncology team communicated your survivorship care plan to your PCP?
Yes
No
Not sure
Do you feel confident managing your post-treatment care with your healthcare team?
Yes
No
Somewhat
Additional Comments or Concerns
Please list any other health concerns or questions you’d like to discuss with your care team.
Submit
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