Susan G. Komen & WCTE Breast Cancer Awareness Campaign

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1. Are you a...

Are you a...   Male Female

2. Do you currently have health insurance?

Do you currently have health insurance?   Yes No

3. What is your age?

What is your age?   20-29 30-39 40-49 50-65+

4. When was your last Mammogram?

When was your last Mammogram?   Never 6 Months or less 1 Year ago 2 Years ago 3+ Years ago

5. On a scale of 1-10, how much do you know about breast cancer and the importance of early detection?
(1= lowest, 10= highest)

On a scale of 1-10, how much do you know about breast cancer and the importance of early detection? (1= lowest, 10= highest)   1-2 3-4 5-6 7-8 9-10