Questions

Q5

Overall, how satisfied are you with your health plan or health insurance?

Q6A

Was there a time during the last 12 months when you needed to see a doctor but could not because of any of the following: The COST?

6A1

What kinds of COSTS? The COST OF APPOINTMENT or the REQUIRED CO-PAYMENT?

6A2

PRESCRIPTION COSTS?

6A3

Any other COSTS?

Q6B

Was there a time in the last 12 months when you needed to see a doctor but could not because of TRANSPORTATION ISSUES?

Q6C

CHILD CARE ISSUES?

Q6D

Are there ANY OTHER REASONS?

Q8

Do you have ONLY ONE person or facility that you think of as your personal doctor or health care provider?

Q9

Do you have MORE THAN ONE person or facility that you think of as your personal doctor or health care provider?

Q14

Are you now trying to lose weight?

Q15

Are you now trying to maintain your current weight that is to keep from gaining weight?

Q16

In the past12 months, has a doctor, nurse or other health professional given you advice about your weight?

Q18

During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers or liquor?

Q22

In the past 12 months, has a doctor, nurse or other health professional ever advised you to reduce or stop drinking alcohol?

Q24

Have you smoked at least 100 cigarettes in your entire life? 100 cigarettes = 5 packs

Q25

Do you NOW smoke cigarettes every day, some days, or not at all?

Q28

During the past 12 months, have you quit smoking for 1 day or longer?

Q30

Has a doctor, nurse or other health professional ever advised you to quit smoking?

Q32

Have you ever been referred by a physician or health care provider for consultation to smoking cessation programs or classes?

32A

Did you attend?

Q34

Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?

Q35

Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?

38A

Have you ever smoked a cigar, even one or two puffs?

38A1

Do you now smoke cigars everyday, some days or not at all?

38B

Have you smoked tobacco in a pipe, even one or two puffs?

38B1

Do you now smoke a pipe every day, some days or not at all?

Q39

In the past 30 days, has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?

Q40

A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?

Q40A

How long has it been since you had your last mammogram?

Q41

A clinical breast exam is when a doctor, nurse or other health professional feels the breast for lumps. Have you ever had a clinical breast exam?

Q42

Do you perform breast self exams?

Q43

A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?

Q44

Has your doctor or health care provider ever suggested you have a Prostate Specific Antigen or PSA blood test to screen for prostate cancer?

44A

Did you have a PSA (Prostate Specific Antigen) blood test performed?

Q45

Have you ever had a digital rectal exam performed by a doctor or health care professional?

Q46

When you go outside on a sunny summer day for more than one hour, how often do you use sunscreen or sunblock?

Q51

A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?

Q52

A sigmoidoscopy (SIG-MOID-OSC-OPY) or colonoscopy (CO-LON-OSC-OPY) is when a tube is inserted into the rectum to view the bowel for signs of cancer and other health problems. Have you ever had this exam?

Q54

Have you ever received a checkup for mouth cancer?

Q56

Have you ever been told by a doctor, nurse or other health professional that you have high blood pressure?

Q60

Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood cholesterol checked?

Q62

Have you ever been told by a doctor or other health professional that your blood cholesterol is high?

64A

To lower your risk of developing heart disease or stroke, are you: Eating fewer high fat or high cholesterol foods?

64B

To lower your risk of developing heart disease or stroke, are you: Exercising more?

65A

To lower your risk of developing heart disease or stroke, has a doctor advised you to: Eat fewer high fat or high cholesterol foods?

65B

To lower your risk of developing heart disease or stroke, has a doctor advised you to : Exercise more

66A

Has a doctor ever told you that you had any of the following: A Heart Attack?

66B

Angina or coronary heart disease?

66C

Stroke?

Q68

Do you take aspirin daily or every other day?

Q71

Do you know what a clinical trial is?

Q73

Have you ever been asked to participate in a clinical trial or medical research study?

73A

Did you participate?

73C

Would you consider participating?

74A

Have you ever heard information on clinical trials from any of the following sources? From PRINTED LITERATURE?

74B

From YOUR DOCTOR?

74C

From the INTERNET or WORLD WIDE WEB?

74D

From CHURCH or a RELIGIOUS LEADER?

74E

From a RADIO BROADCAST?

Q74F

From a COMMUNITY GROUP?

74G

From TELEVISION?

74H

From ANY OTHER SOURCE?

Q75A

Which of the following items would make you more likely to participate in clinical trials? Answer Yes or No to each item. The first item is: Reimbursement for costs?

75B

Insurance coverage of costs?

75C

Transportation provided?

75D

If childcare were provided, would make you more likely to participate in clinical trials?

75E

Would Increased knowledge about clinical trials make you more likely to participate?

Q75F

Benefits to you?

75G

Would a Time Commitment make you more likely to participate in clinical trials?

75H

Not giving your name?

Q75I

Medical follow up after the study?

Q75J

If additional health care or mental health care were provided during the study?

Q76

Has your doctor or health care provider ever discussed clinical trials with you?

Q77

Has your doctor or health care provider ever told you about available clinical trials?