Communicating to Illiterate Populations

PART II - RETURN VISIT UPDATE

(Space to be allotted for addressograph)

NAME: ____________________________

HOSPITAL FACILITY: __________________

DATE OF RETURN VISIT: ______________

MEDICARE NUMBER: __________________

Have you had a mammogram (breast x-ray) since your last visit for a screening mammogram?
Yes No
If Yes, when?
< 1 year ago 1-2 years ago 2-3 years ago
3-5 years ago more than 5 years ago
Have you ever had a physical examination of your breasts by a doctor or other trained health professional?
Yes No
If Yes:
- When was most recent exam?
  less than 1 year ago 1-2 years ago
  2-3 years ago more than 3 years ago
- Who completed the exam?
  a doctor a nurse
  other trained health professional
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? ________