Communicating to Illiterate Populations

Have you ever been taught how to do breast self-examination?
Yes No

If Yes, by whom?
doctor other health professional in a private session
a class pamphlet other
How many times a year do you do breast self-examination?
0 1-3 4-8
9-15 15 or more
If you do breast self-examination, do you feel confident that you are doing it correctly?
Yes No
Have you ever had breast biopsies taken?
No Yes, aspiration/needle biopsy Yes, surgical biopsy
Yes, unsure of type
If Yes:
- How many? _____
- Date of most recent? _____
How old were you when you had your first menstrual period? ________
Have you menstruated in the last year?
Yes No
If No:
- How old were you when your menstrual periods stopped? ____
- Did you have a hysterectomy at that time? Yes No Unknown
- Have you had both ovaries totally removed? Yes No Unknown
Have you ever been pregnant?
Yes No
If Yes:
- Your age when your first child was born? ____
- How many times have you been pregnant (include miscarriages or stillbirths)? ____
- How many children have you had (include stillbirths but do not include miscarriages)? ____
Have you ever taken birth control pills (oral contraceptives)? Yes No
Have you ever taken other estrogen containing drugs (e.g., premarin, climacteron or hormone injections)?
Yes No

If Yes, are you currently taking estrogen (or other hormones)?
Yes No

What is the total number of years you have been taking estrogen? _____