2014 Cancer Awareness Survey Question Title * 1. Your Age 18 – 29 30 – 39 40 – 49 50 – 63 over 64 Question Title * 2. Gender Male Female Question Title * 3. Current Health Status? Excellent Good Fair Poor Question Title * 4. Have you ever been told you have cancer? Yes No Question Title * 5. If yes, what type of cancer did you/do you have? Lung cancer Colon/rectal cancer Breast cancer Prostate cancer Skin cancer Cervical cancer Bladder cancer Leukemia/lymphoma Pancreatic cancer Other Other (please specify) Question Title * 6. If yes, are you being treated for cancer now? Yes No Question Title * 7. If yes, where are you being treated for cancer? Davis Medical Center Cancer Care Center Other Other (please specify) Question Title * 8. If you did not receive your treatment at the Davis Medical Center Cancer Care Center, please select the closest reason for going elsewhere: I was told treatment I needed was not available at the DMC Cancer Care Center My doctor recommended another cancer center I did not know what services were available at the DMC Cancer Care Center I knew about DMC Cancer Care Center, but chose to go to another center. Question Title * 9. Have your biological parents or brothers or sisters had cancer? Yes No Don't Know Question Title * 10. What kind of health insurance do you have? None Medicare Medicaid Private insurance Other Other (please specify) Question Title * 11. What is the biggest obstacle you face in getting health care? Not sure what is available Don’t have insurance Have insurance, but co-pay is too high Don’t have transportation Too difficult with family and/or work Location of services is inconvenient Language barrier Don’t have a regular doctor Too hard to make appointments Question Title * 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) Cancer treatment, chemotherapy Cancer treatment, radiation Cancer treatment, surgery Cancer-information fact sheets and literature Nutrition counseling Cosmetic help, wigs Patient navigation services American Cancer Society contacts and programs Financial counseling Prescription drug payment assistance Screening, mammography Screening, colonoscopy Screening, low-cost lung CT Scan Transportation assistance Pain Management services Patient education Davis House (patient-family housing) Connection to hospice services Home care support and equipment Question Title * 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) Classes and programs about diet and exercise Quit Tobacco programs and resources Health fairs Preventive screenings Community speakers Diabetes education programs Relay for Life Cancer Survivor Dinner Connect to WV Breast & Cervical Cancer Screening Program Betty Gow Breast Cancer Survivor Dinner Connect to local cancer support group Connect to grief counseling and support Other- What other opportunities do you think exist for the Cancer Care Center to meet the cancer needs of our communities and patients? Other (please specify) Question Title * 14. If you are female over age 40, have you ever had a mammogram? Yes No Question Title * 15. If no, please check the reason(s) why not No insurance or coverage Fear pain Don’t like the idea Didn’t know I need one Can’t get to hospital Don’t know how to schedule one Question Title * 16. If you are a woman over age 30, have you had a pap test within the last three years? Yes No Question Title * 17. If no, please check the reason(s) why not: No insurance or coverage Fear pain Don’t like the idea Didn’t know I need one Can’t get to hospital Don’t know how to schedule one Question Title * 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? Yes No Question Title * 19. If no, please check the reason(s) why not: No insurance or coverage Fear pain Don’t like the idea Didn’t know I need one Can’t get to hospital Don’t know how to schedule one Question Title * 20. If you are a man or woman over age 50, have you had at least one screening colonoscopy? Yes No Question Title * 21. If no, please check the reason(s) why not: No insurance or coverage Fear pain Don’t like the idea Didn’t know I need one Can’t get to hospital Don’t know how to schedule one Question Title * 22. How important do you think cancer screenings are to your health? Very Important Somewhat Important Not Important Question Title * 23. If you smoke, has your health care provider ever told you that you need to quit smoking? Yes No Question Title * 24. If you smoke or chew tobacco, how many aids to quitting are you aware of: Local quit smoking (tobacco) classes WV Tobacco Quitline Nicotine Patch or other over-the- counter nicotine replacement product Chantix, Zyban or other prescription medicine On-line support groups Question Title * 25. Are you exposed to other’s smoking in your home, your car, or at work? Yes No Sometimes Question Title * 26. Do you eat 5 – 9 servings of vegetables and fruits (a serving = ½ cup) daily: Always Never Sometimes Question Title * 27. Do you exercise 30 minutes a day, 5 days a week (or 20 minutes a day every day) Always Never Sometimes Question Title * 28. How often do you wear sunscreen when you are outside? Always Never Sometimes Done