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Questions marked with an asterisk (*) are mandatory.
3
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* What is the Zip Code of your current residence?
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4
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Which one would you say is your race?
| White |
| Black or African American |
| Asian |
| Native Hawaiian or Other Pacific Islander |
| American Indian or Alaska Native |
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5
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Are you Hispanic or Latino?
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6
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What is your current marital status?
| Married |
| Divorced |
| Widowed |
| Separated |
| Never married |
| A member of an unmarried couple |
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7
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What is the highest grade or year of school you completed?
| Never attended school or only attended kindergarten |
| Grades 1 through 8 (Elementary) |
| Grades 9 through 11 (Some high school) |
| Grade 12 or GED (High school graduate) |
| College 1 year to 3 years (Some college or technical school) |
| College 4 years or more (College graduate) |
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8
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Which of the following best describes your current employment situation?
| Employed for wages |
| Self-employed |
| Out of work for more than 1 year |
| Out of work for less than 1 year |
| A Homemaker |
| A Student |
| Retired |
| Unable to work |
| Refused |
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9
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What is your annual household income(before taxes) from all sources?
| Less than $15,000 |
| $15,001 to $20,000 |
| $20,001 to $25,000 |
| $25,001 to $35,000 |
| $35,001 to $50,000 |
| $50,001 to $75,000 |
| $75,001 or more |
| Don’t know / Not sure |
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10
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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
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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.
| Within past year (anytime less than 12 months ago) |
| Within past 2 years (1 year but less than 2 years ago) |
| Within past 5 years (2 years but less than 5 years ago) |
| 5 or more years ago |
| Don’t know / Not sure |
| Never |
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12
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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
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* Do you have one person you think of as your personal doctor or health care provider?
| Yes, only one |
| More than one |
| No |
| Don’t know / Not sure |
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14
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How many years have you been a patient of your personal doctor or health care provider?
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15
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At what age do you understand women should begin having annual screening mammograms?
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16
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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
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If you've never had a mammogram, why not?
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18
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How many mammograms have you had?
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19
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How long has it been since you had your last mammogram?
| Within the past year (anytime less than 12 months ago) |
| Within the past 2 years (1 year but less than 2 years ago) |
| Within the past 3 years (2 years but less than 3 years ago) |
| Within the past 5 years (3 years but less than 5 years ago) |
| 5 or more years ago |
| Don’t know / Not sure |
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20
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I believe my getting a mammogram during the next 12 months is necessary.
| 1 | 2 | 3 | 4 | 5 |
| Strongly Disagree |
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| Disagree |
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| Neutral |
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| Agree |
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| Strongly Agree |
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21
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My getting a mammogram would be very difficult to schedule.
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22
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My getting a mammogram would be embarrassing because they have to touch my breasts
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23
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My getting a mammogram would make me worry about getting a diagnosis of breast cancer.
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24
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My getting a mammogram would be unlikely because I tend to put it off.
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25
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Most of the people I know think I should get a mammogram once per year.
| 1 | 2 | 3 | 4 | Don't Know |
| Strongly Disagree |
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| Disagree |
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| Agree |
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| Strongly Agree |
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26
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How much do you feel you are influenced by your doctor to get a mammogram?
| 1 | 2 | 3 | 4 | 5 |
| Not At All |
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| Some |
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| No Opinion |
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| Much |
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| Very Much |
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27
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How much do you feel you are influenced by your spouse or partner in getting a mammogram?
| 1 | 2 | 3 | 4 | 5 |
| Not at all |
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| Some |
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| No Opinion |
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| Much |
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| Very Much |
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28
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How much do you feel you are influenced by your friends in getting a mammogram?
| 1 | 2 | 3 | 4 | 5 |
| Not at All |
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| Some |
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| No Opinion |
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| Much |
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| Very Much |
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29
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How much do you feel you are influenced by your family in getting a mammogram?
| 1 | 2 | 3 | 4 | 5 |
| Not at all |
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| Some |
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| No Opinion |
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| Much |
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| Very Much |
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30
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How much do you feel you are influenced by your girlfriend(s) in getting a mammogram?
| 1 | 2 | 3 | 4 | 5 |
| Not at all |
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| Some |
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| No Opinion |
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| Much |
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| Very Much |
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