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Thank You for helping with this major health issue.

What are we doing? The following questionnaire was developed by medical anthropologists examining the lifestyle causes of breast cancer and lymphedema.  We are gathering preliminary data to determine if further research with other breast cancer survivors is warranted.

 
Who may participate in the questionnaire?  We are seeking real information and experiences from women who have had breast cancer.  If you are currently in treatment for breast cancer, or if you have completed your therapy and treatment, your experiences will be very helpful to us.
 
What does it require of you? Five minutes of your time to answer 16 quick questions.
 
Your privacy will be protected! Any personally identifiable information on your  questionnaire will be stripped from your response (including your e-mail address, unless you asked us to later contact you). Your e-mail address will not be shared, sold, or otherwise used.
 
This process is relatively easy to do:

  1. Move down onto the questionnaire and on each question click on the appropriate choice.

  2. Some answers may more easily be determined if you speak with your partner or spouse (if you have been together since before your first breast cancer diagnosis).

  3. When you finish, click on "Submit Query."

  4. Also, after you submit your responses you will see an abbreviated form on your screen that lists all of your responses.

  5. If you see an obvious error, feel free to return to the questionnaire, respond correctly to just the incorrectly answered question, place the same initials on question #13, and "Submit Query" again.

Thank You! That is all there is too it. You will have the option to receive a response with our results.

If you have ANY questions, do not hesitate to drop a note to Ken at BreastNotes.com

 

BREAST CANCER SURVEY

NUMBER ONE

 

  1. During the five to ten years before you were first diagnosed with breast cancer, would you estimate that:
    A. ...your left breast was larger than your right breast
    B. ...your right breast was larger than your left breast                                            (Choose One)
    C. ...your breasts were pretty much the same size 
    D. I'm not sure

  1. During the five to ten years before you were first diagnosed, what most accurately describes your favorite sleeping position:
    A. On your back
    B. On your front                                                                                                               (Choose One)
    C. On your left side
    D. On your right side
    E. I'm not sure

  1. Before you were diagnosed, which one best choice described your bra-wearing habits:
    A. All day long and usually when I was in bed
    B. Pretty much anytime I was not in bed
    C. More than 12 hours a day                                                                                           (Choose One)
    D. Less than 12 hours a day
    E. Rarely ...or never

  1. At about the time that you were first diagnosed, in which eye did you have better vision?
    A. Left eye
    B. Right eye
    C. I saw equally well in both eyes

  1. At about the time that you were first diagnosed, in which ear did you hear better?
    A. Left ear
    B. Right ear
    C. I heard equally well in both ears

  1. Do you suffer from lymphedema...
    A. ...in your left arm?
    B. ...in your right arm?
    C. ...in both your arms?
    D. I do not have lymphedema in either arm.

  1. What is your current favorite sleeping position (if you had surgery it would be since your surgery has healed)?
    A. On your back
    B. On your front                                                                                                         (Choose One)
    C. On your left side
    D. On your right side
    E. I'm not sure

  1. Has your choice for your current sleeping position been made to prevent or relieve breast or arm swelling?
    A. Yes
    B. No
    C. I'm not sure

  1. Were you first diagnosed with breast cancer in your:
    A. Left breast
    B. Right breast
    C. Both breasts within the same calendar month

  1. Before being first diagnosed for breast cancer, did you experience:
    A. ...tenderness in your breast that lasted for more than a month each time?
              No       If "yes" was it in your Left breast   Right breast or Both breasts
    B. ...cysts (liquid or solid) or lumps ?
              No       If "yes" was it in your Left breast   Right breast or Both breasts

  1. In what year were you born?

  1. In what year were you first diagnosed with breast cancer?

  1.  To prevent our using your data more than once, please place the three initials of your name here (i.e. JFK):

  1. Would you like to receive information about the results of this survey?
               No:   Yes:    To which e-mail address should it be sent? 

  2. Would you be willing to be contacted by us via e-mail for a follow-up or subsequent survey on your breast health?
               No Thank You:       Yes, please do:   at the following e-mail address:

  3. Did you have chemo-therapy?    No:      Yes:  
               If yes, and you know the chemicals that were used, can you name them? 

NOTES:

 

 Thank you very much for helping us out: 

Ken L. Smith
Breast Health Facilitator for ACS
Owner of www.BreastNotes.com

To send this questionnaire in, just click on "Submit Query".     

The American Cancer Society has no connection with this questionnaire and will not participate in the analysis of this data
 

 

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