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?

Where do you live (enter zip code):

Do you have medical insurance?

Yes No