Consent of participant - I certify that I have read, in a language that I understand, all of the components of this form. I understand that my decision to participate will help the community by bringing into limelight the untapped scenarios on late detection, thus helping to save lives. The information I am providing is accurate based on my knowledge.
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Date of Survey
MM
DD
YYYY
Participant Name
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First Name
Last Name
Address of the participant, including Town or Village, State, Country
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Email
Age
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Gender
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Male
Female
Other
If other, please specify (eg. transgender, LGBT or other)
Race, Ethnicity, Language Spoken (Mother tongue)
Education
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Dietary Intake (Food Habit)
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Do you skip meals?
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Often
Sometimes
Never
Workplace
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Do you smoke? Any kind (Cigarette/Biri/Other Forms)
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Light (1-2 cigarettes/day)
Moderate (2-5 cigarettes/day)
Heavy (5+ cigarettes/day)
Quit (Not now but used to earlier)
Never
Do you chew Tobacco in any form?
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Yes
No
Quit (Not now but Earlier used to)
Alcohol consumption
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Regular
Sometimes
Rare
Quit
Never
Lifestyle
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What is your stress level? If you would rate from 1 to 10
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Do you think cancer can spread from one person to another by staying together or by direct or indirect touch? Do you think cancer is contagious?
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Yes
No
Do you take any hormonal medications, e.g contraceptive pills, hormone replacement therapy or others
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If female, were you ever pregnant? How many children you gave birth to and what was your age during your first child delivery? Did you have any history of miscarriages?
Do you know about Breast Cancer in Women?
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Yes
No
If Yes, from where did you get to know about Breast Cancer in Women?
Breast Cancer Hub (BCH)/Thinking Pink Breast Cancer Foundation
Internet, Television, News, etc.
Word of Mouth
Awareness campaign/Seminars/Conference
From Us
Do you know, Men can get Breast Cancer too?
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Yes
No
If Yes, from where did you get to know about Breast Cancer in Men?
Breast Cancer Hub (BCH)/Thinking Pink Breast Cancer Foundation
Internet, Television, News, etc.
Word of Mouth
Awareness campaign/Seminars/Conference
From Us
Do you know young women below the age of 25, or 30 or 40 can get Breast Cancer?
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Yes
No
Do you know young men below the age of 25, 30 or 40 can get Breast Cancer too?
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Yes
No
Do you know that women need to perform Breast Cancer Screening to get detected Early?
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Yes
No
Do you know that men need to perform Breast Cancer Screening to get detected Early?
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Yes
No
Do you know that we have to perform Breast Self Exam from the age of 17-18 years as a screening process for Early Detection to Breast Cancer?
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Yes
No
Did you perform Breast Self Exam from the age of 17-18 years?
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Once a month
Sometimes
Never
Do you know the signs and symptoms of Breast Cancer and the correct method to perform Breast Self Examination?
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Yes
No
If yes, from where did you learn?
Any abnormalities in the Breast detected? For example: Lump, discharge, pain or other symptoms. How did you first feel your symptoms? Is it through Breast Self Exam? If any abnormalities in the Breast, next, did you go to the doctor for further investigation? Did you perform Clinical Breast Exam/Mammogram/Ultrasound? What was your final diagnosis & treatment?
Have you heard about Clinical Breast Exam?
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Yes
No
Did you go to the doctor or nurse to perform Clinical Breast Exam?
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Yes
No
If yes, why did you go for Clinical Breast Exam? Is that because you detected abnormalities in your Breast ? Or you went for regular screening purpose?
If you went to the doctor for Clinical Breast Exam due to screening, then how many times did you go in your lifetime?
Did you hear the word Mammogram?
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Yes
No
Are you above 40 years old?
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Yes
No
If you are above 40, did you perform Screening Mammogram (Mammogram means X-ray of the Breast)?
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Yes
No
I am below 40 years
If yes, then how many times in your lifetime? When you went for mammogram, did you have any issues in the breast or you went for screening with no symptoms or abnomalities
Do you know what dense breast is and how we can find out? Please explain
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Did you perform Mammogram in your lifetime?
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Yes
No
If yes, at what age and was it becasue of issues in the breast or any discharges or lumps or other abnormalities?
If you did mammogram, Did your mammogram show if you have dense breast?
Mildly dense
Moderately dense
Highly dense
Do not know
Not applicable as I never had mammogram
Did you perform Breast Ultrasound in your lifetime?
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Yes
No
If yes, at what age and please specify the reason for doing so? In addition to ultrasound, did you also perform Mammogram?
Do you have Cancer, if yes, then what type of Cancer, at what age and at what stage the cancer was diagnosed? What is the current status of your cancer diagnosis? What kind of treatment did you go through?
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If Breast Cancer, then the receptor type? ER+ or PR+ or HER2+? Do you know the grade of the tumor? Any other details if you would like to mention?
Any family history of Cancer, means someone in your family have/had cancer, includes your parents, uncle, aunt, grandparents or others in your family?
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Yes
No
Not aware of
If yes, name of the patient and your relation with the patient
What type of Cancer and What Stage the cancer was diagnosed? Early or Late Stage or Stage 0, 1, 2, 3 or 4?
What is the current status or cancer stages of the patient?
If you or your family member has cancer, then any genetic testing done for you or your family members ? Example, BRCA1, BRCA2 or other mutation testing?
Did you go for Early detection screening for any type of cancer? If yes, then please elaborate, if it was Early detection screening (when you went to the doctor with no signs and symptoms) or if you had symptoms, so you went to the doctor, for diagnostic tests?
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If you or any of your family member is diagnosed with cancer, do you want us to contact you for counseling & guidance?
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Yes
No
Not affected with Cancer
