Gender
Male
Female

Race
Caucasian
African American
Asian
Hispanic/Latino/a
Mixed Race
Other

Highest Education Level
Grade School
High School
Some College
College Degree (BA, BS)
Graduate School (MD, PhD, JD)

Age:

I have a diagnosis of following type of cancer (eg,breast, prostate, lung, throat etc.):
-- Please Select -- BONE CANCERS —Ewing's Sarcoma —Osteosarcoma —Rhabdomyosarcoma and Other Soft-Tissue Sarcomas BRAIN TUMORS BREAST CANCER ENDOCRINE SYSTEM CANCERS —Adrenal Cancer —Pancreatic Cancer —Parathyroid Cancer —Pituitary Cancer —Thyroid Cancer GASTROINTESTINAL CANCERS —Anal Cancer —Colorectal Cancer —Esophageal Cancer —Gallbladder Cancer —Gastric Cancer —Liver Cancer (Hepatoma) —Pancreatic Cancer —Small Intestine Cancers GYNECOLOGIC CANCERS —Cervical Cancer —Endometrial and Uterine Cancer —Fallopian Tube Cancer —Gestational Trophoblastic Disease and Choriocarcinoma —Ovarian Cancer —Vaginal Cancer —Vulvar Cancer HEAD AND NECK CANCERS —Laryngeal Cancer —Oropharyngeal Cancers —Parathyroid Cancer —Thyroid Cancer LEUKEMIA —Acute Lymphocytic Leukemia (ALL) —Acute Myelogenous Leukemia (AML) —Chronic Lymphocytic Leukemia (CLL) —Chronic Myelogenous Leukemia (CML) —Hairy Cell Leukemia —Myeloproliferative Disorders LUNG CANCERS —Mesothelioma —Non-Small Cell Lung Cancer —Small-Cell Lung Cancer LYMPHOMAS —AIDS-related Lymphoma —Cutaneous T-Cell Lymphoma/Mucosis Fungoides —Hodgkin's Disease —Non-Hodgkin's Disease METASTASES MISCELLANEOUS/OTHER DISEASES —Ataxia-Telangiectasia —Carcinoma of Unknown Primary —Li-Fraumeni Syndrome —Thymoma MYELOMA PENILE CANCER PROSTATE CANCER SARCOMA —Ewing's Sarcoma —Osteosarcoma —Rhabdomyosarcoma and Other Soft-Tissue Sarcomas SKIN CANCER —Cutaneous T-Cell Lymphoma/Mycosis Fungoides —Kaposi's Sarcoma —Melanoma TESTICULAR CANCER THYROID CANCER URINARY TRACT CANCERS —Bladder Cancer —Kidney Cancer —Urethral Cancer

Which cancer treatment(s) have you received? Check off all that apply:
Surgery
Chemotherapy
Radiation
None

Where did you receive your cancer treatments?
Academic medical center
Community hospital
Doctor's office/clinic
None

Resident of:
USA
Canada
United Kingdom
Other (please specify: )

1. Rate your level of concern and interest about nutrition when first diagnosed:
   Very concerned
   Somewhat concerned
   Neutral
   Somewhat unconcerned
   No Interest at all
   
   
2. After you were diagnosed with cancer did you seek information on diet and nutrition?
   Yes
   No
   
   
3. If yes, where did you get information on diet and nutrition? Check off all that apply:
   Internet
   Media (television, radio, newspapers, magazines)
   Books
   Health food stores
   Medical facility (hospital, doctor's office)
   Friends and family
   Other
   
   
4. Please rate the medical team (doctors and nurses) that treated your cancer on the following:
   1. Knowledge about diet and nutrition:
      Very knowledgeable
      Somewhat knowledgeable
      Neutral
      Somewhat unknowledgeable
      Very unknowledgeable
   2. Accepting and responsive to your diet and nutrition concerns:
      Very helpful
      Somewhat accepting/responsive
      Neutral
      Somewhat unaccepting/unresponsive
      Very unaccepting/unresponsive
   
   
5. Was a registered dietitian/nutritionist available to you where you were treated?
   Yes
   No
   I don't know
   
   
6. If yes to 5 , did you receive nutrition counseling from the registered dietitian/nutritionist?
   Yes
   No
   
   
7. If yes to 6 , please rate the dietitian on the following:
   
   1. Dietitian's knowledge about diet and nutrition pertaining to cancer:
      Very knowledgeable
      Somewhat knowledgeable
      Neutral
      Somewhat unknowledgeable
      Very unknowledgeable
   2. Dietitian's helpfulness in dealing with your diet and nutrition concerns:
      Very helpful
      Somewhat helpful
      Neutral
      Somewhat unhelpful
      Very unhelpful
   3. How important was it to have a dietitian available when receiving your cancer treatments:
      Very important
      Somewhat important
      Neutral
      Somewhat unimportant
      Very unimportant
   
   
8. Did you seek nutrition counseling from someone outside of you cancer center?
   Yes
   No
   
   
9. If yes to 8, who provided the nutrition counseling? Check off all that apply:
   Registered dietitian (R.D.)
   Nutritionist but not a registered dietitian (R.D.)
   Naturopath or holistic medicine practitioner
   Chiropractor
   Herbalist
   Chinese medicine practitioner
   Other
   
   
10. Did you tell the doctors and nurses treating your cancer about any unconventional or alternative nutrition therapies or diets that you use e.g. vitamins, supplements, herbs, anti-cancer diets, macrobiotic diets?
    Yes
    No
    Don't use any
    
    
11. If your medical team worked with a registered dietitian/nutrition and you met with them while receiving treatment, did you tell the dietitian about any unconventional or alternative nutrition therapies or diets that you use e.g. vitamins, supplements, herbs, anti-cancer diets, macrobiotic diets?
    Yes
    No
    Don't use any
    Didn't meet with a dietitian
    
    
12. Do you believe that diet and nutrition have an effect on how well a person responds to cancer treatments?
    Yes
    No
    
    
13. Do you believe that your cancer doctors think that diet and nutrition have an effect on how well a person responds to cancer treatments?
    Yes
    No