.:: Patient Resource Reaader Survey Form ::.

Reader Survey Please complete the reader survey below by February 11, 2013 and win a chance to have a $1,000 charitable donation made in your name! For details / rules please click here.
Name:
Email Address:
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Which Patient Resource Cancer Guide publications have you received? Select all that apply	Patient Resource Cancer Guide Patient Resource Cancer Guide: Acute Promyelocytic Leukemia Patient Resource Cancer Guide: Advanced Prostate Cancer Patient Resource Breast Cancer Guide Patient Resource Colorectal Cancer Guide Patient Resource Cancer Guide: Financial Considerations for Patients Patient Resource Cancer Guide: Leukemia, Lymphoma & Multiple Myeloma Patient Resource Lung Cancer Guide Patient Resource Cancer Guide: Medication Adherence Patient Resource Cancer Guide: Personalized Medicine Patient Resource Cancer Guide: Treatment-Related Side Effects Patient Resource Cancer Guide: Understanding Dermatologic Reactions Patient Resource Women's Cancers Guide

Which of the following are you?	Newly Diagnosed Newly restaged (cancer has returned) Survivor for more than five years Caregiver Family Member Healthcare Provider

Which of the following best describes you?	I am researching treatment options I am in treatment for cancer I completed cancer treatment within the past 6 months My family member is being treated for cancer I am a cancer survivor

With which cancer were you or your family member diagnosed? If diagnosed with more than one cancer please select other.	BladderColorectalLungOvarian BreastKidneyLymphomaProstate CervicalLeukemiaMelanomaOther (Please Specify):

What was your age when you were first diagnosed?

Which are you?	MaleFemale

Have you enrolled in a clinical trial or will you consider enrolling in a clinical trial?	YesNo

Would you like to be considered for one of the following?	Featured as a survivor in our next printed guide Featured as a survivor on PatientResource.com

Have you discussed things you have read in one of the Patient Resource Cancer Guide publications with your doctor?	YesNo

Have your decisions about cancer treatment options changed because of something you read in one of the Patient Resource Cancer Guide publications?	YesNo

Have you decided to enroll in a clinical trial because of something you read in one of the Patient Resource Cancer Guide publications?	YesNo

What do you do with the Patient Resource Cancer Guide publications when you are finished reading them?	Save it for future reference Pass it along to someone else Throw it away

What information or type of article would you like to see in the Patient Resource Cancer Guide publications in the future?

For you the patient, what do you consider to be the most important topics covered in Patient Resource Cancer Guide publications?

Sign up to receive our important alerts about new publications that are available, notification of winners of our Patient Resource Oncology Nurse and Reader Survey contests, highlights from all national oncology meetings, new areas of our web site as they become "live" including an area allowing you to keep your family and friends updated on your treatment progress, our featured survivors and alerts on the most exciting announcement of all debuting in January of 2011.	YesNo

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