* 1. Your Age

* 2. Gender

* 3. Current Health Status?

* 4. Have you ever been told you have cancer?

* 5. If yes, what type of cancer did you/do you have?

* 6. If yes, are you being treated for cancer now?

* 7. If yes, where are you being treated for cancer?

* 8. If you did not receive your treatment at the Davis Medical Center Cancer Care Center, please select the closest reason for going elsewhere:

* 9. Have your biological parents or brothers or sisters had cancer?

* 10. What kind of health insurance do you have?

* 11. What is the biggest obstacle you face in getting health care?

* 12. These services are part of Davis Health System’s comprehensive cancer care program. How many of them are you already aware of? (check all that apply)

* 13. These things are part of Davis’s comprehensive cancer program for the community. Which ones did you already know about? (check all that apply)

* 14. If you are female over age 40, have you ever had a mammogram?

* 15. If no, please check the reason(s) why not

* 16. If you are a woman over age 30, have you had a pap test within the last three years?

* 17. If no, please check the reason(s) why not:

* 18. If you are a man over age 50, have you had a PSA (prostate) blood test and a digital rectal exam to screen for prostate cancer?

* 19. If no, please check the reason(s) why not:

* 20. If you are a man or woman over age 50, have you had at least one screening colonoscopy?

* 21. If no, please check the reason(s) why not:

* 22. How important do you think cancer screenings are to your health?

* 23. If you smoke, has your health care provider ever told you that you need to quit smoking?

* 24. If you smoke or chew tobacco, how many aids to quitting are you aware of:

* 25. Are you exposed to other’s smoking in your home, your car, or at work?

* 26. Do you eat 5 – 9 servings of vegetables and fruits (a serving = ½ cup) daily:

* 27. Do you exercise 30 minutes a day, 5 days a week (or 20 minutes a day every day)

* 28. How often do you wear sunscreen when you are outside?

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