Tell us about Yourself

In order to better serve the community it would help us if we get to know you. Just click on answers.

Have you ever had a cancer screening? Yes No

If so, what kind of screening? (click on more than one answer if you have had more than one test): Mammography Pap Test Sigmoidoscopy Hemocult PSA testing

Do you currently smoke? Yes No

Do you want to quit smoking? Yes No

Do you know anybody with cancer?

Friends

Myself

Family

Are you: Male Female

What level of schooling have you completed:

No official schooling Elementary school High School

Vocational School College Graduate School

How old are you? Select your age range 19 or younger 20 to 29 30 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 79 80 to 89 90 and up

Where do you live (enter zip code):

Do you have medical insurance? Yes No