1. Have you ever had a primary care doctor?

Yes No

If No, who do you see for regular follow up?

OB/GYN (gynecologist)

Specialists, please specify:

2. Have you changed (switched) primary care doctor since your cancer diagnosis?

No Yes

If Yes, What is the main reason for the change?

Change in insurance

Change of residence

I don't like my previous primary care physician

3. How long have you known your current primary care doctor?

Less than 1 year 1-4 years 5-9 years 10 years or greater

4. How often have you seen your primary care doctor since the diagnosis of your cancer?

Not at all Once/yr 2-4 times/yr 5-11 times/yr
monthly or more

5. How much do you trust your primary care physician has your best interest as a patient?

6. Please tell us how much you agree with each statement about your primary care physician's ability to take care of you as a cancer survivor by checking the appropriate box:

7. How satisfied are you with your primary care doctor's care?

Not at all A little bit Somewhat Moderately Very Much

8. How well does your primary care doctor and oncologist(s) work together to treat you as a patient?

Outstanding Excellent Good Average Poor