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* 1. Have you ever had cancer?

* 2. Has anyone in your immediate family had cancer (please choose all that apply)?

* 3. How often do you do the following?

  Monthly Annually Every two to four years Every five to seven years Never (N/A)
Self breast or scrotum exam
Mammogram
Exam of breasts or scrotum by doctor or nurse
PAP test
Complete skin exam by dermatologist
Blood or stool test for cancer indications
Colonoscopy

* 4. How strong is your fear that you or someone you love will get cancer?

  Very strong Moderate Weak
Self
Immediate family
Friends

* 5. Please describe your three closest encounters with cancer (e.g. “I had a cancerous skin lesion removed,” “My mother is a breast cancer survivor,” “A boy in my fifth-grade class died of leukemia," etc.

* 6. Describe any experience you have had fighting cancer in general, not your own illness (e.g. contributing time or money, participating in Relay for Life, doing medical research, being a caregiver to a cancer patient, etc.) Please describe your experience in as much detail as you are willing to give.

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