What is your age? 20-35
36-50
51-65
65+
*

What type of cancer do you have (e.g. breast, lung, colon, other)?

What is your current status? (Check all that apply) Just diagnosed
Pre-surgery
Post-surgery
Undergoing chemotherapy
Undergoing radiation

Other/Let me descibe

Please describe your status:

Describe any physical changes or side effects you are experiencing from treatment. (Check all that apply) Fatigue
Weight gain
Weight loss
Hair loss
Hair regrowth
Skin issues
Post-surgery issues: swelling, scarring, incision issues
Drain Management
Lymphedema
Limited arm mobiity
Changes in eating and/or taste:Eating Changes

Other/Let me describe

Please describe any other changes:

What are some of the challenges you face in an effort to feel good about the way you look and feel?

What situations do you find yourself in that require our product and style ideas? (Check all that apply) Resting & recovery
Work/office
School
Dating
Family, friends & social events
Exercising
Casual

Other/Let me describe

Please tell us a bit about your style and the things you enjoy wearing.

Describe your situations:

Your Name *

Contact Email *

What is the recipient's approximate age? 20-35
36-50
51-65
65+
*

What is the type of cancer (e.g. breast, lung, colon, other)?

What is the current status? (Check all that apply) Just diagnosed
Pre-surgery
Post-surgery
Undergoing chemotherapy
Undergoing radiation

Other/Let me describe

Describe any physical changes or side effects, if possible, that would help us suggest a gift. (Check all that apply) Weight gain
Weight loss
Hair loss
Hair regrowth
Skin issues
Post-surgery issues: swelling, scarring, incision issues
Lymphedema
Limited arm mobiity

Other/Let me describe

Please describe any other changes:

Share with us the things she enjoys doing (i.e. reading, listening to music, walking, yoga, gardening, family games, etc.).

Are there accessories that she likes i.e. hats, scarves, earrings, necklaces, bracelets, handbags?

Describe your situations:

Your Name *

Contact Email *

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