MARKET RESEARCH SURVEY

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MARKET RESEARCH SURVEY

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First Name*

Last Name*

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Additional Information For Your Survey(s)

1 X MARKET RESEARCH SURVEY

How frequently do you visit the doctor or make an appointment?

Required

When was your last mammogram / years since last screening?

Required

What is your age group?

Required

What is your race / ethnicity?

Required

Do you currently have health insurance?

Required

Have you had breast cancer?

Required

Has anyone in your immediate family had breast cancer?

Required

Do you know someone affected by breast cancer?

Required

Do you know how to do a self-breast exam?

Required

What are some barriers for women who do not get a mammogram? Select all that apply.

Required

Beliefs

Fears

Transportation

Cost

Can't get away / Off from work

Lack of childcare for the appointment

It’s uncomfortable

Other

How do you prefer to hear medical information?

Required

Your doctor

Other medical professionals

Community presentations / health fairs

Someone who has personal knowledge / experience

Local health departments

Media (radio, tv, movies)

Social Media (Facebook, Twitter, Instagram, Internet Ads, etc.)

Your own research

Have you heard about the BarbaraCares Mammogram’s Matter Program that provides coverage for uninsured, underinsured, and at-risk women to receive a mammogram?

Required

Gender Identity. Do you identify as

Required

Are you aware of any health fairs or community resources in your area?

Required

Would you like to see more health fairs offered at community centers in this area?

Required

What zip code do you live in?

Optional

Characters Remaining: 500

How many people are in your home?

Required

How many children, below 18 are in your home?

Required

Do you agree to be contacted via phone, email or mailing list for a follow-up?

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By clicking I agree to the terms.

Your Details

Additional Information For Your Survey(s)

1 X MARKET RESEARCH SURVEY

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