1. What is your ethnicity?

(Check all that apply) [ ]1 Asian/Pacific Islander [ ]2 African American [ ]3 Hispanic [ ]4 Caucasian/ White [ ]5 Other: ________ 2. What is your age? (Only Check One) [ ]121-30 years old [ ]231-40 years old [ ]3 41-50 years old [ ]4 51-60 years old [ ]5 61 years old and above 3. Are you currently a smoker? (Only Check One) [ ]1Yes [ ]2No

4. How would you describe your physical activity level: (Circle only one) None Lightly Active Moderately Active Highly Active 1 2 3 4 5. Consuming alcohol can increase the chance of developing breast cancer. (Circle only one) Strongly Disagree 1 Disagree 2 Neutral 3 Agree 4 Strongly Agree 5

6. Have you ever been diagnosed with the following conditions: (Check all that apply) [ ]1alcoholism [ ]4obesity [ ]2high cholesterol [ ]5diabetes [ ]3high blood pressure [ ]6stroke 7. At what age is it recommended for average-risk women to receive a mammogram? (Only Check One) [ ]115 years old [ ]228 years old [ ]335 years old [ ]440 years old

8. You can perform a self-examination of each breast to check for any abnormalities. [ ]1True [ ]2False 9. Is there a family history of breast cancer? If so, what is their relation(s) to you? _____________________________________________________________________________________ _____________________________________________________________________________________ 10. Do you currently have health coverage? (Only Check One) [ ]1Yes [ ]2No [ ]3In the process of getting insured