MARKET RESEARCH SURVEY

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

When was your last mammogram / years since last screening?*

What is your age group?*

What is your race / ethnicity?*

Do you currently have health insurance?*

Have you had breast cancer?*

Has anyone in your immediate family had breast cancer?*

Do you know someone affected by breast cancer?*

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

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

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?*

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?*

Gender Identity. Do you identify as*

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

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

What zip code do you live in?

How many people are in your home?*

How many children, below 18 are in your home?*

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

MARKET RESEARCH SURVEY

Contact Info

Additional Information for Your Survey(s)

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