questionnaire

Introduction*

The information used to generate report will be reviewed annually and updated as appropriate based on the most current available evidence. As your medical team may have access to new data before this site is next updated, their medical advice may differ from what is contained in this report. Always rely on the advice of your medical team.

Do you wish to continue?

Yes, please continue.

No, please exit.

Privacy Statement*

All data are collected and stored by CCRAN, a registered Canadian non-profit patient-led support and advocacy group. To ensure patient and caregiver privacy and confidentiality, individual responses will be anonymized and will not be identifiable. It is important to note that your information will be stored in a safe database without reference to your name or any other identifying information. The data will be used to help CCRAN better understand the growing trends in the management of colorectal cancer.

Do you agree with the following statement: “I agree that this information is being provided voluntarily and by providing this information I consent to its use by CCRAN for internal research and statistical purposes.”?

Yes, I agree.

No, I disagree (please exit).

Have you been diagnosed with colorectal cancer or are you caring for someone who has been diagnosed with colorectal cancer?*

Yes

No

If yes, what stage of colorectal cancer do you have?*

What year were you born?*

Where do you live?

What was your gender assigned at birth?*

Male

Female

What is your current gender [or gender identity]?*

Male

Female

Non-binary

Prefer to self-describe

Are you currently undergoing treatment with drug therapy (i.e., treatment with chemotherapy, targeted therapy, immunotherapy, or some combination of these)?*

Yes

No, I am newly diagnosed and have not yet had any treatments with drug therapy.

Are you receiving treatment with a granulocyte colony-stimulating factor (GCSF) such as filgrastim (Neupogen®) or pegfilgrastim (Lapelga®)?*

Yes

No

Don't know

Thank you for completing this questionnaire. The following is a summary of your answers.

{all_fields:nohidden}

Please review carefully. If you need to revise any answers, you can do so by clicking the previous button until you reach your answer and editing the relevant question. Once you are satisfied that you have answered each question accurately, press the “Submit” button below to generate your individualized report. Note: This could take up to 5 minutes depending upon the number of side effects you have selected.
If you are experiencing technical issues accessing your report or need assistance, please email cassandra.m@ccran.org

Will you be receiving treatment with a granulocyte colony-stimulating factor (GCSF) such as filgrastim (Neupogen®) or pegfilgrastim (Lapelga®)?*

Yes

No

Don't know

Thank you for completing this questionnaire. The following is a summary of your answers.

{all_fields:nohidden}

Please review carefully. If you need to revise any answers, you can do so by clicking the previous button until you reach your answer and editing the relevant question. Once you are satisfied that you have answered each question accurately, press the “Submit” button below to generate your individualized report. Note: This could take up to 5 minutes depending upon the number of side effects you have selected.
If you are experiencing technical issues accessing your report or need assistance, please email cassandra.m@ccran.org

Let’s Get Started!

Questionnaire