NET Treatment and Wellness Plan Pilot - Patient Evaluation Survey

Question Title

* 1. What is your gender?

Male

Female

Other (please specify)

Question Title

* 2. Which category below includes your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

Question Title

* 3. Do you live in a metropolitan or rural area?

Metropolitan (within one hour drive of capitol city centre)

Regional (over one hour drive from capitol city centre)

Question Title

* 4. Are you of Aboriginal or Torres Strait Islander heritage?

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Question Title

* 5. What statement best describes your current situation?

I have completed my treatment for NETs

I am having ongoing treatment (e.g. Sandostatin/Lanreotide injections)

Other (please describe)

Question Title

* 6. How did you hear about the treatment and wellness plan? (select all that apply)

Unicorn Foundation E-News

Unicorn Foundation Website

Unicorn Foundation Facebook Page

Unicorn Foundation Facebook Private Discussion Group

Unicorn Foundation NET Nurse

Australian Cancer Survivorship Centre

Other Health Professional

Support Group

Other (please specify)

Question Title

* 7. Who completed your treatment and wellness plan? (select all that apply)

Specialist (e.g. Oncologist)

Care coordinator (e.g. Nurse)

Self-completed

Other (please specify)

Question Title

* 8. Please tell us how much you agree with the following statements about the treatment and wellness plan:

	Strongly disagree				Strongly agree	N/A
I had a thorough record of my treatment and investigations to date	I had a thorough record of my treatment and investigations to date Strongly disagree	I had a thorough record of my treatment and investigations to date	I had a thorough record of my treatment and investigations to date	I had a thorough record of my treatment and investigations to date	I had a thorough record of my treatment and investigations to date Strongly agree	I had a thorough record of my treatment and investigations to date N/A
I understood my plan of treatment	I understood my plan of treatment Strongly disagree	I understood my plan of treatment	I understood my plan of treatment	I understood my plan of treatment	I understood my plan of treatment Strongly agree	I understood my plan of treatment N/A
I had a record of, and understood future investigations/ monitoring	I had a record of, and understood future investigations/ monitoring Strongly disagree	I had a record of, and understood future investigations/ monitoring	I had a record of, and understood future investigations/ monitoring	I had a record of, and understood future investigations/ monitoring	I had a record of, and understood future investigations/ monitoring Strongly agree	I had a record of, and understood future investigations/ monitoring N/A
I had a record of other professionals involved in my care	I had a record of other professionals involved in my care Strongly disagree	I had a record of other professionals involved in my care	I had a record of other professionals involved in my care	I had a record of other professionals involved in my care	I had a record of other professionals involved in my care Strongly agree	I had a record of other professionals involved in my care N/A
I had a record of how and when to contact other health professionals	I had a record of how and when to contact other health professionals Strongly disagree	I had a record of how and when to contact other health professionals	I had a record of how and when to contact other health professionals	I had a record of how and when to contact other health professionals	I had a record of how and when to contact other health professionals Strongly agree	I had a record of how and when to contact other health professionals N/A
I had adequate information about maintaining and improving my general health	I had adequate information about maintaining and improving my general health Strongly disagree	I had adequate information about maintaining and improving my general health	I had adequate information about maintaining and improving my general health	I had adequate information about maintaining and improving my general health	I had adequate information about maintaining and improving my general health Strongly agree	I had adequate information about maintaining and improving my general health N/A
The plan reduced my worries about my condition	The plan reduced my worries about my condition Strongly disagree	The plan reduced my worries about my condition	The plan reduced my worries about my condition	The plan reduced my worries about my condition	The plan reduced my worries about my condition Strongly agree	The plan reduced my worries about my condition N/A
The plan helped me know how I can contribute to the management of my condition	The plan helped me know how I can contribute to the management of my condition Strongly disagree	The plan helped me know how I can contribute to the management of my condition	The plan helped me know how I can contribute to the management of my condition	The plan helped me know how I can contribute to the management of my condition	The plan helped me know how I can contribute to the management of my condition Strongly agree	The plan helped me know how I can contribute to the management of my condition N/A
The plan encouraged me to become more active in order to improve my condition	The plan encouraged me to become more active in order to improve my condition Strongly disagree	The plan encouraged me to become more active in order to improve my condition	The plan encouraged me to become more active in order to improve my condition	The plan encouraged me to become more active in order to improve my condition	The plan encouraged me to become more active in order to improve my condition Strongly agree	The plan encouraged me to become more active in order to improve my condition N/A

Comments

Question Title

* 9. Overall, how satisfied were you with this document?

Not at all satisfied

Extremely satisfied

Not at all satisfied

Extremely satisfied

Question Title

* 10. In what format would you prefer this plan? (please select all that apply)

Paper based

Online

Via an app

Comments

Question Title

* 11. Would you envisage sharing this document with your GP?

Yes

Comments

Question Title

* 12. Is there anything you would change about the document?

Yes

Comments:

Question Title

* 13. Thank you for your feedback. Is there anything else you would like to add?

We would love you to join us for our next webinar which will look at diagnostic imaging in NETs.
Stay tuned for more information via our website or Facebook page very soon!

Question Title

* 14. If a health professional helped you complete your plan, would you be happy to share their details so we can ask them what they think?

Name

Hospital/organisation

Email Address

Phone Number