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Q2 Country of birth
Q3 Religion
Q4 Highest attained level of education
Q5 Employment status:
Muslim
Christian
Jewish
Hindu
Buddhist
Non-religious
Other religions (please specify)
No formal education
Primary school
Secondary
Diploma
Undergraduate degree
Postgraduate degree
Other (please specify)
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Q6 Number of years employed
Q7 Marital status
Q8 If you have children, how many?
Q9 What is your/your family’s average annual income?
Unemployed (go to Question 7)
Full time
Part time
Casual/Contract
Other (please specify)
Married
Widowed
Divorced
Separated
Never married
De facto
Under $20,000
$20,000 - $49,999
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Q10 What is your ethnicity?
Q11 In what year did you migrate to Australia?
Q12 What language do you speak at home?
$50,000 - $99,999
$100,000 - $149,999
$150,000 -$199,999
$200,000 +
Please specify
Migration for (years)
Born in Australia
Arabic
Bengali
Burmese
Cantonese
English
Greek
Hindi
Italian
Malay
Mandarin
Punjabi
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Q13 How do you rate your English speaking ability?
Q14 What is the area code of the suburb you live currently?
Cancer history
Cancer history and your breast cancer knowledge prior to diagnosis of
breast cancer.
Q1 How long ago were you diagnosed breast cancer?
Q2 Has any of your family members ever had breast cancer?
Spanish
Vietnamese
Others (please specify)
Poor
Satisfactory
Fluent
Very fluent
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Q3 How did your breast cancer was diagnosed?
Q4 What did you know about the symptoms of Breast Cancer before
your diagnosis? (Tick all that apply)
Q5 What did you know about how to diagnose breast cancer prior to
your diagnosis? (Tick all that apply)
Yes
No
Brest self examination
Clinical examination by a doctor
Mammography
Other (please specify)
Lump
Changed size or shape of breasts
Nipple discharge
Crusting, ulcer or redness of nipples
Redness or dimpling of breast
Swollen underarms
Breast swelling
Not sure
Breast self examination
Clinical breast examination by a doctor
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Q6 What did you know about are the treatment options available for
breast cancer before your diagnosis? (Tick all that apply)
Q7 What was your main source of information for breast cancer? (Tick
all that apply)
Q8 Do you find it difficult to discuss your breast cancer with friends,
family, or your community?
Mammography
Ultrasound
MRI
Not sure
Prescription drugs
Chemotherapy
Surgery
Radiation therapy
Hormone therapy
Not sure
Doctor or nurses
Friends and family
Media (radio, TV, newspaper)
Internet
Other (please specify)
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Q9 What do you believe your chances of recurring breast cancer in
the future are?
Q10 Which of the following do you believe the diagnosis of breast
cancer has threaten (tick all that apply)
BR23
Patients sometimes report that they have the following symptoms or
Yes No
Friends
Family
Own Community
Very unlikely
Unlikely
Neutral
Likely
Very likely
Marriage or relationship
Career
Family relationship
Ability to care for my family
No threat
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problems. Please indicate the extent to which you have experienced
these symptoms or problems during the past week.
For the past week,
Not at all A little Quite a bit Very much
Did you have a
dry mouth?
Did food and
drink taste
different than
usual?

Were your eyes
painful, irritated
or watery?

Have you lost
any hair?
Answer this
question only if
you had any hair
loss: Were you
upset by the
loss of your
hair?

Did you feel ill or
unwell?
Did you have
hot flushes?
Did you have
headaches?
Have you felt
physically less
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During the past four weeks:
attractive as a
result of your
disease or
treatment?

Have you been
feeling less
feminine as a
result of your
disease or
treatment?

Did you find it
difficult to look at
yourself naked?

Have you been
dissatisfied with
your body?

Were you
worried about
your health in
the future?

Not at all A little Quite a bit Very much
To what extent
were you
interested in
sex?

To what extent
were you
sexually active?
(with or without
intercourse)

Answer this
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During the past week:
question only if
you have been
sexually active:
To what extent
was sex
enjoyable for
you?

Not at all A little Quite a bit Very much
Did you have
any pain in your
arm or
shoulder?

Did you have a
swollen arm or
hand?

Was it difficult to
raise your arm
or to move it
sideways?

Have you had
any pain in the
area of your
affected breast?

Was the area of
your affected
breast swollen?

Was the area of
your affected
breast
oversensitive?

Have you had
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What type of treatment/s were you gone through? (Tick all that apply)
What were the side effects of your cancer treatment? (Tick all that
apply)
Psychological distress (K6)
skin problems
on or in the area
of your affected
breast (e.g.,
itchy, dry, flaky)?

Surgery
Lumpectomy
Mastectomy
Chemotherapy
Radiotherapy
Medication
Other (please specify)
Fatigue
Headaches
Pain and numbness
Dental issues
Lymphedema
Bone loss and osteoporosis
Heart problems
Other (please specify)
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The following questions ask about how you have been feeling during
the past 30 days. For each question, please circle the number that
best describes how often you had this feeling.
Q1 During the past 30 days, about how often did you feel ...
Q2 The last six questions asked about feelings that might have
occurred during the past 30 days. Taking them altogether, did these
feelings occur More often in the past 30 days than is usual for you,
about the same as usual, or less often than usual? (If you never have
any of these feelings, circle response option “4.”)

All of the
time (1)
Most of
the time
(2)
Some of
the time
(3)
A little of
the time
(4)
None of
the time
(5)
a. nervous?
b. hopeless?
c. restless or
fidgety?
d. so depressed
that nothing
could cheer you
up?

e. that
everything was
an effort?

f. worthless?
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Q3 During the past 30 days, how many days out of 30 were you totally
unable to work or carry out your normal activities because of these
feelings? Please enter number of days below.
Q4 Not counting the days you reported in response to Q3, how many
days in the past 30 were you able to do only half or less of what you
would normally have been able to do, because of these feelings?
Please enter number of days below.
Q5 During the past 30 days, how many times did you see a doctor or
other health professional about these feelings? Please enter number
of days below.
More often than usual
A lot
Some
A little
About the same as usual
Less often than usual
A lot
Some
A little
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Q6
Quality of life questions (QoL-30)
We are interested in some things about you and your health. Please
answer all of the questions yourself by choosing the number that best
applies to you. There are no "right" or "wrong" answers. The
information that you provide will remain strictly confidential.
Click to write the question text

All of the
time (1)
Most of
the time
(2)
Some of
the time
(3)
A little of
the time
(4)
None of
the time
(5)
During the past
30 days, how
often have
physical health
problems been
the main cause
of these
feelings?


Not at all
(1) A little (2)
Quiet a bit
(3)
Very much
(4)
1. Do you have
any trouble
doing strenuous
activities, like
carrying a heavy
shopping bag or

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During the past week:
a suitcase?
2. Do you have
any trouble
taking a long
walk?

3. Do you have
any trouble
taking a short
walk outside of
the house?

4. Do you need
to stay in bed or
a chair during
the day?

5. Do you need
help with eating,
dressing,
washing yourself
or using the
toilet?


Not at all
(1) A little (2)
Quiet a bit
(3)
Very much
(4)
1. Were you
limited in doing
either your work
or other daily
activities?

2. Were you
limited in
pursuing your
hobbies or other
leisure time

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activities?
3. Were you
short of breath?
4. Have you had
pain?
5. Did you need
to rest?
6. Have you had
trouble
sleeping?

7. Have you felt
weak?
8. Have you
lacked appetite?
9. Have you felt
nauseated?
10. Have you
vomited?
11. Have you
been
constipated?

12. Have you
had diarrhea?
13. Were you
tired?
14. Did pain
interfere with
your daily
activities?

15. Have you
had difficulty in
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concentrating on
things, like
reading a
newspaper or
watching
television?

16. Did you feel
tense?
17. Did you
worry?
18. Did you feel
irritable?
19. Did you feel
depressed?
20. Have you
had difficulty
remembering
things?

21. Has your
physical
condition or
medical
treatment
interfered with
your family life?

22. Has your
physical
condition or
medical
treatment
interfered with
your social
activities?

23. Has your
physical
condition or
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For the following questions please choose the number between 1 and
7 that best applies to you
Multidimensional Scale of Perceived Social Support (MSPSS)
We are interested in how you feel about the following statements
concerning social support. Read each statement carefully. Indicate
how you feel about each statement. The items tended to divide into
factor groups relating to the (Fam), friends (Fri) or significant other
(SO).
Click to write the question text
medical
treatment
caused you
financial
difficulties?


How would you
rate your overall
health during the
past week?

How would you
rate your overall
quality of life
during the past
week?

Very poor Excellent
1 2 3 4 5 6 7
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Very
Strongly
Disagree
(1)
Strongly
Disagree
(2)
Mildly
Disagree
(3)
Neutral
(4)
Mildly
Agree
(5)
Strongly
Agree
(6)
Very
Strongly
Agree
There is a
special
person
who is
around
when I
am in
need.
(SO)

There is a
special
person
with
whom I
can share
my joys
and
sorrows.
(SO)

My family
really
tries to
help me.
(Fam)

I get the
emotional
help and
support I
need
from my
family.
(Fam)

I have a
special
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person
who is a
real
source of
comfort to
me. (SO)

My
friends
really try
to help
me. (Fri)

I can
count on
my
friends
when
things go
wrong.
(Fri)

I can talk
about my
problems
with my
family.
(Fam)

I have
friends
with
whom I
can share
my joys
and
sorrows.
(Fri)

There is a
special
person in
my life
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Health services utilisation
Health services utilisation
Q1 Which health services currently available to you (Tick all that
apply)
who
cares
about my
feelings.
(SO)

My family
is willing
to help
me make
decisions.
(Fam)

I can talk
about my
problems
with my
friends.
(Fri)

General practitioner (GP)
Reproductive services
Doctor’s surgery
Specialist services
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Q2 Which health services did you utilise during your cancer
treatment? (Tick all that apply)
Q3 Which health services currently using ? (Tick all that apply)
Q4 Which health services are not currently available to you?
Q5 What health services (including reproductive health) would you like
to have access to improve your health?
General practitioner (GP)
Reproductive services
Doctor’s surgery
Specialist services
General practitioner (GP)
Reproductive services
Doctor’s surgery
Specialist services
General practitioner (GP)
Reproductive services
Doctor’s surgery
Specialist services