*1.
Please tell us the first and last name of the child diagnosed with cancer. (Maximum response 255 chars, approx. 5 rows of text)
*2.
Please tell us what type of cancer or disease
the child was diagnosed with?
3.
What was the approximate date of cancer
diagnosis?
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
*4.
How old was the patient when diagnosed?
*5.
How long was the patient in treatment?
6.
Please tell us a bit about your family when
the patient was diagnosed. Where did the
family live at the time (city/state)?
*7.
Please list the first names and ages of
siblings of the patient at the time of
diagnosis.
8.
What were some of the patients and/or the
family interests at the time of diagnosis?
*9.
Please tell us how you found out about the
child's diagnosis.
*10.
Please tell us about some of the feelings the
patient/family had after the initial diagnosis?
*11.
Please tell us where the child was treated for
their illness?
12.
Please tell us what types of treatment the
patient received:
Please make up to 4 selections from the choices below.
13.
Did the childhood cancer patient have any
experimental therapies used on them while
being treated? Or, were they part of any
clinical trials?
14.
Tell us about any special friendships that
were made while the child was being treated
for cancer.
15.
Please tell us a bit about your experiences
with the doctors and nurses while the patient
was being treated.
16.
Was there a special toy or item that was
important for the child to have with them
during treatment?
*17.
Did the child survive their battle with
childhood cancer?
Please select response
Yes
No
18.
What was the worst thing about your
experience with childhood cancer?
19.
Were there any good things that happened
as a result of your experience with childhood
cancer?
20.
Are there any lasting effects that the cancer
patient or their family has endured as a result
of the treatments received?
21.
Please tell us a bit about your family since
treatment for cancer has finished (health,
school, activities):
22.
Are there any special messages you would
like to pass along to others regarding the
importance of childhood cancer research?
23.
Are there any special messages you would
like to pass along to children that are
currently undergoing cancer treatment?
*24.
I am at least 18 years of age or have my
parents/guardians permission to share this
information.
Please select response
Yes
No
25.
Please give us the first and last name of one
of your parents/guardians if you are under 18
years of age.
