Lung Cancer Questionnaire for Caregivers Question Title * 1. How old was the patient when diagnosed with lung cancer? Younger than 30 years old 31 – 40 years old 41 – 50 years old 51 – 60 years old 61 – 70 years old 71 years old or greater Question Title * 2. Is the patient currently receiving or has received chemotherapy in the past 3 years? Yes No Question Title * 3. Does/did the person experience side effects from his/her chemotherapy? Yes No Question Title * 4. Which of the following side effects is the patient experiencing or has experienced due to chemotherapy? Check all that apply. Nausea, vomiting, diarrhea Loss of appetite Fatigue Insomnia Rash Pain Tingling in hands or feet Hair loss Breathing problems Mouth sores Question Title * 5. How much do you agree or disagree with the following: The patient finds/ found it difficult to take every dose of chemotherapy Strongly disagree Disagree Neutral Agree Strongly agree Question Title * 6. Which of the following reasons makes/ made it difficult for the patient to take chemotherapy? Check all that apply. Side effects of chemotherapy Chemotherapy schedule Cost of chemotherapy Other Other (please specify) Question Title * 7. How much do you agree or disagree with the following: Chemotherapy disturbs/disturbed the patient’s normal daily activities Strongly disagree Disagree Neutral Agree Strongly agree If you answered "agree" or "strongly agree," please describe how does/ did chemotherapy disturb the patient’s normal daily activities Question Title * 8. How much do you agree or disagree with the following: Chemotherapy disturbs/disturbed the patient’s family life Strongly disagree Disagree Neutral Agree Strongly agree If you answered "agree" or "strongly agree," please describe how chemotherapy disturbs/ disturbed the patient's family life Question Title * 9. How much do you agree or disagree with the following: Chemotherapy causes/ caused financial problems Strongly disagree Disagree Neutral Agree Strongly agree If you answered "agree" or "strongly agree," please describe how chemotherapy causes/ caused financial problems. Question Title * 10. How much do you agree or disagree with the following: The administration of chemotherapy is/ was inconvenient Strongly disagree Disagree Neutral Agree Strongly agree If you answered "agree" or "strongly agree," please describe how administration of chemotherapy is/ was inconvenient Done