Patient / Survivor Questionnaire

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1 thanks
2 release agreement
3 Diagnosis
4 Side Affects
5 finances
6 support

Hey Friend,


Thank you so much for taking the time to share your story. 


Below is an idea of some questions we may ask during our recording. We hope that providing these ahead of time gives folks an opportunity to recollect their experiences.


It also helps us to be more familiar with your story in case there are certain aspects we'd like to chat more about.  Feel free to skip those that don't apply.


We truly believe that creating this resource of personal experiences can help us all along this journey.


All the best,

Lena & Kristina


PS - This form is automatically saved as you type. If the form is not submitted, you can come back to it later on and continue from where you left off. Please note that the data is only stored for 60 days.

Pre-Interview Questions for Cancer Patients or Survivors
Release Agreement

I hereby grant to Hell No Cancer Show (HNCS) , their employees, subsidiaries, affiliates, agents, successors, and assigns the right and permission to record, use, publish, stream live, offer for sale, or otherwise distribute any audio or video interview with me. Such right and permission includes, but is not limited to, my name, recorded voice or video, photograph or likeness, biographical information, handouts or any material based upon or derived therefrom.


I understand that HNCS may, at its sole discretion, produce presentations or publications based in whole or in part upon audio interview (or any portions thereof) and/or a video or audio recordings or photographs of said interview, and that such media or transcripts may appear in print, online, or in any manner of/or media, including but not limited to promoting the podcast or streaming audio program.


I have no right of approval, no claim for compensation, and no claim (including, without limitation, claims based upon invasion of privacy, defamation, or right of publicity) arising out of or in connection with, any use, alteration, or use in any composite form hereunder. I hereby warrant and represent that I have the right to enter into this agreement and to grant the rights granted to HNCS herein.


I agree that during the course of the interview I have not violated the rights of any third parties, including but not limited to copyrights, rights of privacy, trade secrets, and non-disclosure agreements, and that in the event of any breach of any of these warranties, that I will defend and hold HNCS harmless and without indemnity against any such claims. This release shall be binding upon me and my heirs, legal representatives, and assigns.

First Name
Last Name
Phone Number
Do you wish for your published interview to be anonymous?We prefer that folks not remain anonymous so that others can better connect with you and your story. But we understand that in some cases anonymity is necessary and we're totally cool with that.
What should we call you?
How did you discover that you had cancer?i.e. signs and symptoms
0 /
When were you diagnosed?
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What types of tests did you go through during your diagnosis process ?i.e. blood work, scans, biopsy, etc.
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What type and stage of cancer were you diagnosed with?
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What was your prognosis?What where your chances of beating this thing?
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Did you feel well supported by your medical team?
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What is your current status?
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Do you worry about a reoccurance?
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What type of treatment did you go through?i.e. chemotherapy, radiation, surgery, etc.
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What were the side affects?i.e. nausea, hair loss, fatigue,etc.
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What helped you most in dealing with the side effects?i.e. teas, lotions, foods, etc.
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Did you lose your hair? How did you handle it?
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Did you work throughout your treatment?
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If not, how long was it until you returned to work? How did you know you were ready to go back?
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How did you pass the time during your treatment sessions or time off of work?i.e. reading, podcasts, audiobooks, sleeping, excercising, etc.
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Were you able to utilize any assistance programs?(I.e. FMLA or disability)
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Did you have insurance? And how did it impact you financially?
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How did your friends & family respond?
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How did your employer and co-workers respond?
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Were there any books, movies, websites, songs, poems, scriptures, etc. you found helpful?
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Did you participate in any support groups, forums, therapy, faith based groups, etc.?
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How did you handle transitioning back to "everyday life"? Did you have any aftercare?
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What did you look forward to most after finishing treatment?
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What was more challenging than you expected?
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What was better than you expected?
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What was your funniest or most embarrassing moment?
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If you were making a care package for yourself, what would you include?
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How has life changed since cancer so rudely interrupted it?
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If you could go back in time to when you were first diagnosed and give yourself one piece of advice, what would it be?
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Is there anything you'd like to add? Or questions you'd like to hear in future episodes?
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Do you have a blog, podcast or other project that you're currently involved in that you'd like to mention?
Project Name
Project Description
0 /
Project Website
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Say HELL NO to cancer getting the best of us!
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Say HELL NO to cancer getting the best of us!
Get notified whenever we share a new story.
Your information will never, ever be shared with a third party. Pinky swear.