Age:

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* 2.

Age:

What is the Zip Code of your current residence?

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* 3.

What is the Zip Code of your current residence?

Which one would you say is your race?

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* 4.

Which one would you say is your race?

Are you Hispanic or Latino?

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* 5.

Are you Hispanic or Latino?

What is your current marital status?

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* 6. What is your current marital status?

What is the highest grade or year of school you completed?

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* 7. What is the highest grade or year of school you completed?

Which of the following best describes your current employment situation?

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* 8. Which of the following best describes your current employment situation?

What is your annual household income(before taxes) from all sources?

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* 9. What is your annual household income(before taxes) from all sources?

  Was there a time in the past 12 months when you needed to see a doctor but could not

because of cost?

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* 10.

  Was there a time in the past 12 months when you needed to see a doctor but could not

because of cost?

   About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a

 general physical exam, not an exam for a specific injury, illness, or condition.

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* 11.

   About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a

 general physical exam, not an exam for a specific injury, illness, or condition.

 Do you have any kind of health care coverage, including health insurance, prepaid plans

such as HMOs, or government plans such as Medicare?

 

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* 12.

 Do you have any kind of health care coverage, including health insurance, prepaid plans

such as HMOs, or government plans such as Medicare?

 

Do you have one person you think of as your personal doctor or health care provider?

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* 13. Do you have one person you think of as your personal doctor or health care provider?

 How many years have you been a patient of your personal doctor or health care provider?

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* 14.

 How many years have you been a patient of your personal doctor or health care provider?

At what age do you understand women should begin having annual screening mammograms?

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* 15.

At what age do you understand women should begin having annual screening mammograms?

A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

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* 16.

A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

If you've never had a mammogram, why not?

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* 17.

If you've never had a mammogram, why not?

 How many mammograms have you had?

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* 18.

 How many mammograms have you had?

 How long has it been since you had your last mammogram?

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* 19.

 How long has it been since you had your last mammogram?

I believe my getting a mammogram during the next 12 months is necessary.

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* 20.

I believe my getting a mammogram during the next 12 months is necessary.

My getting a mammogram would be very difficult to schedule.

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* 21. My getting a mammogram would be very difficult to schedule.

My getting a mammogram would be embarrassing because they have to touch my breasts

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* 22. My getting a mammogram would be embarrassing because they have to touch my breasts

My getting a mammogram would make me worry about getting a diagnosis of breast cancer.

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* 23. My getting a mammogram would make me worry about getting a diagnosis of breast cancer.

My getting a mammogram would be unlikely because I tend to put it off.

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* 24.

My getting a mammogram would be unlikely because I tend to put it off.

  Most of the people I know think I should get a mammogram once per year.

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* 25.

  Most of the people I know think I should get a mammogram once per year.

How much do you feel you are influenced by your doctor to get a mammogram?

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* 26.

How much do you feel you are influenced by your doctor to get a mammogram?

 How much do you feel you are influenced by your spouse or partner in getting a mammogram?

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* 27.

 How much do you feel you are influenced by your spouse or partner in getting a mammogram?

How much do you feel you are influenced by your friends in getting a mammogram?

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* 28.

How much do you feel you are influenced by your friends in getting a mammogram?

How much do you feel you are influenced by your family in getting a mammogram?

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* 29.

How much do you feel you are influenced by your family in getting a mammogram?

How much do you feel you are influenced by your girlfriend(s) in getting a mammogram?

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* 30.

How much do you feel you are influenced by your girlfriend(s) in getting a mammogram?

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