I. Demographics
Country
Current Age
Relationship Status
Age at diagnosis
Belonging to any Survivors Group?
II. Late Effects of Childhood Cancer
Q1.1
Have you heard about late effects of childhood cancer?
Q1.2
Introduction and Examples of Late Effects of Childhood Cancer
Health problems that develop years later because of a cancer treatment are known as late effects. Depending on what treatment/drug you had received, some common examples of late effects arisen from cancer treatment are listed below for reference:
Chemotherapy
- Heart problems
- Hearing loss
- Osteoporosis
- Infertility
- Early menopause
- Etc.
|
Radiotherapy
- Memory problems
- Increased risk of stroke
- Lymphedema
- Etc.
|
Hormone Therapy
- Body pain
- Frequent urination
- Nightmares
- Stomache ache
- Etc.
|
After reading the above information, please answer the following question:
Do you think you have been told about late effects of childhood cancer before filling out this questionnaire?
Q2.2
Did your care givers / doctors tell you about late effects and follow-ups before you completed your treatment?
Q2.4
Do you attend any follow-up consultations / treatments for your late effects?
Q3
Would you like to know (more) about late effects?
Q5
Whom do you prefer to ask/consult about late effects? (You may choose up to three options.)
III. Quality of Survivors' Life
Q7
While under treatment, did you ever have to stop going to school?
Q8
Highest Educational Attainment
Q9
At what age did you have to stop going to school?
(If you had to stop multiple times, please indicate age at which you first had to stop schooling and other ages as well.)
Q10
In total, how long did you stop schooling, because of your cancer treatment or other cancer related factors
(e.g. family no longer had money for my schooling due to expenses of treatment, etc)
Q11
Do you think that cancer survivors are discriminated against?
Q12
Have you ever been rejected for a job due to your cancer history?
Q13
Have you ever lost any relationship with your friends / partners because you told them you had cancer?
Q14
Have you ever felt hopeless about your future because you had cancer?
Q15
Have you ever felt ashamed that you had cancer?
Q16
Do you sometimes feel guilty that you are a survivor while others were not as lucky?
Q17
Did you find yourself losing interest in activities you previously found enjoyable or liked doing?
Q18
Are there occasions you experience fear or anger, with no real reasons for it?
Q19
Which of the following actions should a survivor take to stay healthy? (You may choose more than one option.)
Q20
Please rate the following about your recent physical conditions after surviving childhood cancer.
Q20.1
Fatigue
(1 being severe and 10 being no such issue)
Q20.2
Sleep Quality
(1 being extremely bad and 10 being extremely good)
Q20.3
Musculoskeletal Complications, such as: muscle stiffness, joint pain, general aches etc.
(1 being severe and 10 being no such issue)
Q20.4
Body Image Concern
(1 being very concerned and 10 being no such concern)