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Welcome to Genetic Pre-Screening Test
This quick survey helps us understand why some women skip breast cancer checks. Your answers are private and will connect you to free help if needed. Takes ~5 min.
15
Questions
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1
What's your full name?
First Name
Last Name
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2
How old are you?
Click to type
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3
What's your household income?
Under $30K
$30-50K
$50-75K
Over $75K
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4
What's your highest education?
Some high school
High school grad
Some college
College grad+
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5
Do you have health insurance?
YES
NO
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6
How far is your nearest doctor's office/clinic?
Under 30 min drive
30-60 min
Over 60 min
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7
What best describes you?
White
Black
Hispanic
Other
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8
Preferred language?
English
Spanish
Other
Type option 4
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9
Do you have a personal or family history of any of these kinds of cancer?
YES
NO
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10
Have you had a mammogram within the past 3 years?
YES
NO
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11
Where and when have you had a mammogram within the past 3 years?
If you answered YES to the previous question - if no you can skip this question
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12
Would you like us to sign you up for a Goldilocks breast cancer screening program?
YES
NO
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13
Do you have a facility preference for your mammogram?
If you answered YES to the previous question (4) - if no you can skip this question
YES
NO
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14
Which facility do you prefer?
If you answered YES to the previous question - if no you can skip this question
Surgical Care of the Virginias
Community Radiology of Virginia
Princeton Community Hospital
Clinch Valley Medical Center
Welch Community Hospital
Other
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15
What's your Phone Number?
Please enter a valid phone number.
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