Bunko for Breast Cancer - Needs Assessment

Bunko for Breast Cancer is committed to serving the growing needs of breast cancer survivors. By completing this survey, you are helping us design and shape the programs and services we offer. We want to learn more about you! Thank you in advance for taking the time to fill out this survey.

Contact Information

Name: *
Phone:
Email:
Address 1:
Address 2:
City: *
State: *
Zip Code:
What is the best way for us to stay in contact with you? *PhoneEmailEmail or phone is fine

Personal Information

How old are you? *
Who lives with you? *
How many children do you have? *

Do you have children in the following age groups?

	Under the age of 5 *	YesNo
	6-9 years old *	YesNo
	10-12 years old *	YesNo
	13-18 years old *	YesNo
	19 years old or over *	YesNo

What kind(s) of health insurance do you have? *
What is your current employment status? *

Breast Cancer Information

In what year were you FIRST diagnosed with breast cancer? *
Please choose ONE statement that BEST describes your current treatment status *
Currently, how easy is it for you to maintain your usual daily routines and activities? *
Please select the appropriate answer for each of the following treatments:

Chemotherapy *

Radiation *

Surgery/Recovering from Surgery *

Hormonal Therapy *

Biological Therapy *

Experimental treatment in clinical trials *

Pain *

Anxiety or Panic Attacks *

Depression *

Fatigue or Weakness *

Trouble sleeping *

Nausea or Vomiting *

Neuropathy (numbness, tingling or pain in hands or feet) *

Hand-foot syndrone (red or sore hands or feet) *

Mouth Sores *

Hot Flashes *

Hair Loss *

other changes in appearance *

Trouble with memory, concentration or organization *

Problems with appetite *

Problems with sexuality *

Vaginal dryness or discomfort with sex *

Support System

Since your diagnosis, have you had a desire for a support group? * YesNo
What type of support do you most prefer? *
What type of moderator/leader do you most prefer? *
Professionally led by a nurse, social worker, psychologist or counselor
Led by a breast cancer survivor
No leader: we run the group ourselves
No preference

What educational programs do you most desire? (check all that apply) *

Current treatment options
New treatments and the latest research
Clinical trials information
Symptoms and side effects
Pain management

Communicating with your doctor and healthcare team
Parenting issues
Complementary and holistic medicine
Hospice and end-of-life care
Advance directives

What type of support services do you most desire? (check all that apply) *

Stress management skills (relaxation, meditation, yoga)
Support group
Individual counseling
Family or couples counseling

Counseling for children
Guidance and help with spiritual issues
Buddy program
Prayer support

What type of practical information and services do you most desire? (check all that apply) *
Books/resources regarding treatment plans
Books/resources regarding diagnosis
Help with meals
Help with laundry or house-cleaning
Books/resources for speaking with family members about diagnosis
Other If other, please specify:

Other Sources of Information

Who is your primary caregiver? * If other, please specify:
How did you hear about Bunko for Breast Cancer and our services?
Other information you would like us to know:

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