Survivorship Questionnaire

Section 1: Demographics

Study ID Auto-generated unique ID

Patient Initials

Age

Gender

Time Since Treatment

Place of Residence

Education Level

Occupation

Impact on Employment

Monthly Household Income

₹

Marital Status

Has Marital Status Changed recently?

Yes

No

Living Arrangement

Any New Health Problems?

Section 2: Habit History

Section 3: Financial Impact

Financial difficulties affected treatment?

Yes

No

Financial issues affect follow-up visits?

Yes

No

Health Insurance

Received financial assistance from Hospital?

Yes

No

Received assistance from NGO?

Yes

No

Out of Pocket Expenses

₹

Section 4: Functional Health

Question

Strongly Disagree (1) Strongly Agree (5)

Difficulty in shoulder/neck movement

1

2

3

4

5

Able to perform personal tasks

1

2

3

4

5

Able to perform household activities

1

2

3

4

5

Able to perform physical activity

1

2

3

4

5

Experience breathlessness

1

2

3

4

5

Experience cough

1

2

3

4

5

Experience numbness

1

2

3

4

5

Recurrent infections

1

2

3

4

5

Satisfaction with sexual life

1

2

3

4

5

Quality of sleep

1

2

3

4

5

Experience fatigue

1

2

3

4

5

Concentration difficulty

1

2

3

4

5

Able to fulfill work responsibilities

1

2

3

4

5

Difficulty in traveling

1

2

3

4

5

Section 4: Oral Health

Question

Strongly Disagree (1) Strongly Agree (5)

Difficulty opening mouth

1

2

3

4

5

Dry mouth

1

2

3

4

5

Oral ulcers

1

2

3

4

5

Loss of teeth

1

2

3

4

5

Difficulty chewing solid food

1

2

3

4

5

Difficulty swallowing

1

2

3

4

5

Pain or sensitivity in teeth/gums

1

2

3

4

5

Altered taste

1

2

3

4

5

Change in voice

1

2

3

4

5

Clarity of speech

1

2

3

4

5

Social Status & Emotional Well-being

Social Status

Question

Strongly Disagree (1) Strongly Agree (5)

Participation in social activities

1

2

3

4

5

Comfortable eating in public

1

2

3

4

5

Comfortable traveling alone

1

2

3

4

5

Concern about appearance

1

2

3

4

5

Difficulty speaking on phone

1

2

3

4

5

Difficulty speaking in public

1

2

3

4

5

Comfortable discussing health

1

2

3

4

5

Feel stigmatized

1

2

3

4

5

Confidence in speech

1

2

3

4

5

Emotional Well-being

Question

Strongly Disagree (1) Strongly Agree (5)

Fear of recurrence

1

2

3

4

5

Feeling sad or anxious

1

2

3

4

5

Motivation level

1

2

3

4

5

Adaptation to new normal

1

2

3

4

5

Feeling isolated

1

2

3

4

5

Support from family

1

2

3

4

5

Feeling like a burden

1

2

3

4

5

Self Care & Financial Well-being

Self Care

Question

Strongly Disagree (1) Strongly Agree (5)

Perform self-exams

1

2

3

4

5

Attend physiotherapy

1

2

3

4

5

Aware of recurrence signs

1

2

3

4

5

Part of support group

1

2

3

4

5

Know contact info for emergencies

1

2

3

4

5

Financial Well-being

Question

Strongly Disagree (1) Strongly Agree (5)

Burdened by treatment cost

1

2

3

4

5

Dental care affordability

1

2

3

4

5

Medicine affordability

1

2

3

4

5

Able to attend follow-ups

1

2

3

4

5

Section 5: Qualitative Feedback

Difficulties faced in the hospital?

Suggestions for service improvement?

Specific financial challenges?

Section 1: Demographics

Section 2: Habit History

Tobacco Details

Section 3: Financial Impact

Section 4: Functional Health

Section 4: Oral Health

Social Status & Emotional Well-being

Social Status

Emotional Well-being

Self Care & Financial Well-being

Self Care

Financial Well-being

Section 5: Qualitative Feedback