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Survivor Questionnaire
 
 
Name *
 
Address *
   
Zip Code *
County
   
Phone Number *
   
Email Address *
How long have you lived at your current residence?
Where were you living when you were diagnosed?
Race and Ethnicity
 
DOB *
Marital Status
Do you have any children
If yes: What are their ages and gender
At time of diagnosis, did you have medical insurance?
 
Age at diagnosis *
 
Year of diagnosis *
Type and Stage of breast cancer?
Family history of breast cancer?
Did you have genetic testing?
If yes, what was the results of the test?
How did you discover your breast cancer?
Explain your treatment (surgery, radiation, chemotherapy, reconstruction)?
A specific memory througout your journey?
Any recurrence?
Did you participate in a support group?
What is your involvement with Komen for the Cure?
Which of the following media are you comfortable participating with upon your permission?


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