Patient Perceptions of Proton Therapy Survey

The following survey will help us to understand common patient perceptions of proton therapy.

Background


Male
Female




If other, please specify:




Urban (city)
Suburban (Near city)
Rural (Country side)


USA
Canada
Other Country


(please select all that apply):
Acute Lymphocytic Leukemia
Acute Myeloid Leukemia
Anal Cancer
Appendiceal Cancer
Bladder Cancer
Brain Cancer
Breast Cancer
Cervical Cancer
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Colon Cancer
Endometrial Cancer
Esophageal Cancer
Fallopian Tube Cancer
Gall Bladder / Cholangiocarcinoma
Head & Neck: Tongue, Lip, Oropharynx, Nasopharynx
Hodgkin's Disease
Kidney Cancer
Liver Cancer
Lung Cancer
Lymphoma
Melanoma
Mesothelioma
Multiple Myeloma
Non-Melanoma Skin Cancers
None
Other Cancer
Ovarian Cancer / Primary Peritoneal Cancer
Pancreatic Cancer
Penile Cancer
Prostate Cancer
Rectal Cancer
Sarcoma
Stomach Cancer
Testicular Cancer
Thymoma or Thymic Carcinoma
Thyroid Cancer
Uterine cancer
Vaginal and Vulvar Cancers

If you have not previously been diagnosed with cancer, please indicate your relationship to the patient:

(Please select all that apply )
Surgery
Radiation
Chemotherapy
Hormone Treatment


Yes
No


0
1
2
3
4 or more


0
1-4
5-9
10-14
15 or more


0
1-4
5-9
10-14
15 or more


Yes
No

English

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