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* 2.

Age:

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* 3.

What is the Zip Code of your current residence?

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* 4.

Which one would you say is your race?

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* 5.

Are you Hispanic or Latino?

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* 6. What is your current marital status?

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

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

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

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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?

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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.

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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?

 

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* 13. Do you have one person you think of as 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?

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* 15.

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

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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?

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* 17.

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

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* 18.

 How many mammograms have you had?

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* 19.

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

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* 20.

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

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

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

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

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* 24.

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

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* 25.

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

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* 26.

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

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* 27.

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

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* 28.

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

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* 29.

How much do you feel you are influenced by your family 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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