1.	What type of cancer were you diagnosed with? Please be as specific as possible.
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2.	Did you receive chemotherapy?			[Circle one]		Yes	No	Don’t know
		a. If yes, what chemotherapy drugs did you receive? Please be as specific as possible and list all you can recall.
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3.	Did you receive radiation therapy?			[Circle one]		Yes	No	Don’t know
		a. If yes, to what parts of your body did you receive radiation treatment?
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4.	Did you have any surgeries as part of your treatments?
				[Circle one]		Yes	No	Don’t know
		a. If yes, what types of surgeries? Please list below.
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5.	Do you feel that previous treatments you received for cancer could cause serious future health problems?
				[Circle one]		Yes	No	Don’t know
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6.	I know what I can do to reduce my risk for certain kinds of complications from my cancer treatments.
	Strongly Disagree	1	2	3	4	5	6	Strongly Agree