Liver Cancer Screening Awareness and Prevalence Study Questionnaire
1. Have you ever been diagnosed with a liver disease? ☐ No ☐ Yes 1.1. If YES, what was the name of the diagnosis? ______________
2. Have you ever been diagnosed as having any type of cancer? ☐ No ☐ Yes 2.1 If YES, what cancer was it? _________________________
3. Has any blood relative in your immediate family ever been diagnosed as having any type of cancer?
☐ No ☐ Yes
4. Has your doctor or other health care professional ever talked to you about colorectal cancer screening like sigmoidoscopy, colonoscopy, or a stool test (FOBT)? ☐ No ☐ Yes
IF THE PARTICIPANT IS A MAN:
5. Has your doctor or other health care professional ever talked to you about prostate cancer screening like PSA blood test or digital rectal exam? ☐ No ☐ Yes
IF THE PARTICIPANT IS A WOMAN:
6. Has your doctor or other health care professional ever talked to you about breast cancer screening like mammogram? ☐ No ☐ Yes
7. DURING THE LAST 12 MONTHS, how many times have you seen a doctor or other health care professional about your own health at doctor’s office, a clinic, or some other place? (Do not include times you were hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits, or telephone calls.)
☐ None ☐1 ☐ 2-3 ☐ 4-9 ☐ 10 or more
8. Has your doctor or other health care professional ever talked with you about liver cancer?
☐ No ☐ Yes
9. Have you ever heard of ultrasound, CT scan, or MRI for liver to find if a person has liver cancer?
☐ No ☐ Yes
9.1. If YES, where did you hear about it? (Mark all that apply) ☐ 1. - Doctor or other health care professional
☐ 2. - Friends, family, coworkers
☐ 3. - Website, social network, newspaper, radio ☐ 1 and 2
☐ 1 and 3
☐ 2 and 3
☐ All of the above
10. Do you currently smoke cigarettes or have you stopped?
☐ Never smoked ☐ Currently smoke ☐ Stopped smoking 11. DURING THE LAST 12 MONTHS, how often did you have a drink containing alcohol?
☐ Never ☐ less than three times per month
☐ 1-3 times per week ☐ 4-6 times per week ☐ Everyday
12. DURING THE LAST 12 MONTHS, how many alcoholic drinks did you have on a typical day when you drank alcohol? ___________ drinks
13. Would you say your health in general is:
☐ Excellent? ☐ Very good? ☐ Good? ☐ Fair? ☐ Poor?
14. What is the highest grade or level of schooling you completed?
☐ Less than high school ☐ Completed high school
☐ Post-high school training or some college ☐ Collage graduate
