Cancer Pain Management & Cannabis Research Study

Full Name

Phone Number

Email Address

City and State of Residence

County of Residence

Date of Birth

Format: Month/Day/Year (e.g., 01/15/1980)

Gender

Male Female Other Prefer not to respond

Race/Ethnicity

American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Other (please specify)

Please specify your race/ethnicity

Do you consent to be contacted for future research studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

Have you ever been diagnosed with cancer by a healthcare provider?

Yes No

Please select the type of cancer you were diagnosed with.

If you have been diagnosed with cancer more than once, please select your most recent cancer.

Please specify your cancer type

In what year were you first diagnosed with this cancer?

Please enter a 4-digit year.

What best describes your cancer at the time of diagnosis?

I was diagnosed with cancer that had spread (metastatic) I was diagnosed with cancer that had not spread (non-metastatic)

What best describes your current cancer treatment status?

I am currently receiving cancer treatment I have completed treatment and still have cancer I have completed treatment and have no evidence of cancer

What type of cancer treatment are you currently receiving?

Chemotherapy Radiation Immunotherapy Hormone Therapy Other (please specify)

Please specify your other treatment

About cannabis use

The next few questions ask about your use of cannabis products — sometimes also known as marijuana, pot, weed, or products containing CBD or THC — in any form, including smoking, vaping, edibles, dabbing, or others.

Have you used cannabis to help manage pain related to your cancer?

Yes No

Please select the type of cannabis product you have used to help manage pain related to your cancer.

Products containing THC (tetrahydrocannabinol) CBD-only products (cannabidiol, no THC)

Select the option that best describes what you have used.

How frequently do you use cannabis to help manage pain or other symptoms related to your cancer?

Daily or almost daily Weekly Monthly Less than monthly I no longer use cannabis

When did you stop using cannabis?

Less than 6 months ago 6-12 months ago 1-2 years ago More than 2 years ago

Before you stopped, how frequently did you use cannabis?

Daily or almost daily Weekly Monthly Less than monthly

Are you comfortable participating in a 45-minute Zoom interview with video?

Yes No

Cancer Pain Management & Cannabis Research Study - Screening Questionnaire