Colon Health Survey

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* 1. How old are you?

18-29

30-39

40-49

50-59

60-69

70-79

79 and older

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* 2. What is your gender?

Male

Female

Two-Spirit

Prefer not to disclose

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* 3. What would you say your health is?

Excellent

Very Good

Fair

Poor

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* 4. Do you use Tobacco?

Yes

No

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* 5. During a normal week, do you spend 2.5 hours (30 minutes a day for 5 days a week), participating in physical activities such as running, fishing, golfing, gardening, bowling, attending a fitness class, or walking for exercise?

Yes

No

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* 6. Does your fruit and vegetable intake impact your risk of cancer?

True

False

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* 7. Have you been screened for colorectal cancer?

Yes.

No

If yes, did you have a colonoscopy or use a Fit Kit?

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* 8. Have you ever had cancer of the colon or rectum?

Yes

No

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* 9. Has anyone in your family been diagnosed with colon cancer?

Yes

No

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* 10. Did you put off screenings due to Covid-19?

Yes

No

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* 11. Would you be interested in learning more about colon health and available resources?

Yes

No

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* 12. Are you a member of SPIPA's Health and Wellness Facebook group?

Yes

No

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* 13. Which Tribe are you associated with?

Skokomish

Shoalwater Bay

Nisqually

Squaxin Island

Chehalis

Other (please specify)

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* 14. Please provide your name and phone number for raffle prize

Name

Phone Number