1. Please select your gender:
Male
Female

2. Please indicate your current age:
Please Select 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Over 100

3. Please indicate your racial background (select one):
Please Select African American Asian/Pacific Islander Caucasian Latino/Hispanic Mixed Race Other
If other, please specify:

4. Please indicate the highest level of education completed:
Please Select Less than 8th grade 8-11th grade High School Diploma Associate Degree Bachelor's Degree More than a Bachelor's Degree

5. Please indicate your annual household income bracket for the 2009 calendar year:
Please Select Less than $19,999 $20,000-$49,999 $50,000-$99,999 More than $100,000

6. Please indicate where you live:
Urban (city)
Suburban (Near city)
Rural (Country side)

And your geographical location:
USA Please Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Canada Please Select Provinces Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Other Country Please Select Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Icel And India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Dem People'S Republic Korea, Republic Of Kuwait Kyrgyzstan Lao People'S Dem Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Ant Illes New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint K Itts And Nevis Saint Lucia Saint Vincent, The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia , S Sandwich Is. Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard, Jan Mayen Islands Sw Aziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Is. Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe

7. Please indicate your age at cancer diagnosis:
Please Select 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Over 100

8. Please indicate the type of cancer diagnosed (please select all that apply):
Acute Lymphocytic Leukemia
Acute Myeloid Leukemia
Anal Cancer
Appendiceal Cancer
Bladder Cancer
Brain Cancer
Breast Cancer
Cervical Cancer
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Colon Cancer
Endometrial Cancer
Esophageal Cancer
Fallopian Tube Cancer
Gall Bladder / Cholangiocarcinoma
Head & Neck: Tongue, Lip, Oropharynx, Nasopharynx
Hodgkin's Disease
Kidney Cancer
Liver Cancer
Lung Cancer
Lymphoma
Melanoma
Mesothelioma
Multiple Myeloma
Non-Melanoma Skin Cancers
None
Other Cancer
Ovarian Cancer / Primary Peritoneal Cancer
Pancreatic Cancer
Penile Cancer
Prostate Cancer
Rectal Cancer
Sarcoma
Stomach Cancer
Testicular Cancer
Thymoma or Thymic Carcinoma
Thyroid Cancer
Uterine cancer
Vaginal and Vulvar Cancers

If you have not previously been diagnosed with cancer, please indicate your relationship to the patient:
Please Select Not applicable (I have been previously diagnosed with cancer) Family member or friend Healthcare provider (Nurse, NP, Physician, other)

9. Please indicate the types of treatment you have received: (Please select all that apply )
Surgery
Radiation
Chemotherapy
Hormone Treatment
Other

10. Please indicate whether you have undergone remission as a result of treatment:
Yes
No

11 If not, please indicate how many additional treatments you have undergone:
0
1
2
3
4 or more

12. Please indicate the number of different prescription drugs you take regularly:
0
1-4
5-9
10-14
15 or more

13. Please indicate the number of different nonprescription drugs you take regularly:
0
1-4
5-9
10-14
15 or more

14. Please indicate whether you have ever been enrolled in a study to evaluate a new drug, therapy, medical device (implant, pacemaker, etc), or a new surgical procedure:
Yes
No