Potential Benefits and Risks of Mammograms Questionnaire

Potential Benefits & Risks of Mammograms Questionnaire

Q1. What is your year of birth? 19 Example "32"
Q2. How many screening mammograms have you ever had?
Q3. How old were you when you had your first screening mammogram?
Q4. When did you have your most recent screening mammogram?
Q5. Who made the decision that you have your most recent screening mammogram?
Q6. Which personal factor has had the most influence on your decision to have or not have a mammogram? (Please select one column only)
Have a mammogram Not have a mammogram
Q7. Who or what information source has had the most influence on your decision to have or not have a mammogram? (Please select one)
 
Q8. Whether or not you have had a mammogram, which of the following experiences best describes your interaction with your doctor or health care provider (Please select one)
 
Q9. How many of the questions and answers in the "Potential Benefits and Risks of Mammograms" have you read?
Q10. How much do you agree or disagree with the following statement?
"I understand the benefits and risks of routine mammograms."
Q11. How likely is it that having routine mammograms will prevent breast cancer deaths in women in their forties?
Q12. How likely is it that having routine mammograms will prevent breast cancer deaths in women in their fifties and sixties?
Q13. How common is it for a woman to have an abnormal mammogram result if she undergoes routine mammograms?
Q14. Which of the following best describes your intent about screening mammograms? (Pick one only)
I have never had a screening mammogram and have no intention of getting one
I have never had a screening mammogram but will start getting them by age
I have had one or more mammograms and have no intention of getting another one
I don't know what I will do about getting a mammogram in the future
I will discuss with my doctor before deciding what to do about mammograms
I have had a screening mammogram but will wait to get my next one until age
I will continue to get screening mammograms every 1 to 2 years
Q15. How has the information presented in the "Potential Benefits and Risks of Mammograms" questions and answers affected your decision-making about screening mammograms?
Q16. Have any of your BLOOD relatives ever been diagnosed with breast cancer?
(Please pick Yes, No, or Don't Know for each of the following)
Relative Yes No Don't know N/A  
Mother  
Sister(s)  
Daughter(s)  
Aunt(s)  
Grandmother(s)  
Q17. Has a doctor ever told you that you have breast cancer? Yes No Not sure
Q18. How old were you when your first child was born?
Q19. How many years of schooling have you had? (Please fill in one)
Q20. What is your racial background? (Please check all that apply)
White or Caucasian Hispanic Japanese
Black or African American Vietnamese Filipina
Native American Chinese Other race
If you checked "Other race" please specify: