Name and location of clinic:

How did you hear about it?

What year(s) did you visit the clinic?

What type of cancer did you/your child have?

Age at diagnosis:

As of today, how many years is it since diagnosis:

At the time of the late effects clinic visit, how many years were you/your child off treatment?

Were you mixed in with kids on treatment or is the clinic held at a different time or in a different space from kids on treatment?

Did they give you a summary of your treatment and a list of your follow up needs?

Did they refer you to any specialists?

Did they give you any wellness education (e.g., not smoking, weight, exercise etc)?

How was the clinic staffed: was there only one nurse or was there a full team of specialists, nurses, nurse practioners?

Did the staff seem to have expertise in survivor medical, education, psychological and educational issues?

How knowledgeable did the staff seem about survivor issues?

How did you feel about the information that you were given and the way you were treated?

Does the clinic provide ongoing care or just a one-time consultation?

How far did you have to travel for treatment. Was it worth it?

How difficult (or easy) was it to get health care coverage of the visit? (This might not be an issue if there is no clinic within the vicinity of your health care coverage; any input is appreciated.)

Did they provide help or suggestions about how to obtain old medical records, and/or did they ask for old medical records?

If you were too old to be seen in their clinic on a regular basis, did they refer you to a knowledgeable health care provider?

Would you go back?

Number of stars: 5 is an excellent rating, 1 is a poor rating.

Additional comments:

Power to the people.