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Study ID: (e.g. 2306-5,563-190)

1. What is your date of birth?

1 2 3 4 5 6 7 8 9 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /19

2. With which ethnic group do you identify yourself?

	Caucasion/Non-Hispanic		Asian/Pacific Islander		African-American
	Native American		Latino/Hispanic		Other

3. What is your current marital status?

	Single		Divorced		Married/living with partner
	Widowed		Separated		Other:

4. What is the highest grade or level of formal education that you have completed?

	None		Elementary school (8 years)		Some high school		High school (12 years)
	Some college		College graduate		Graduate school		graduate or professional degree

5. What is your current occupation?


6. How much did your family, which includes yourself and spouse (if there is one) earn in total for last year? (Does not include other relatives or friends in household)

	Less than $15,000
	At least $15,000, but less than $25,000?
	At least $25,000, but lss than $35,000?
	At least $35,000, but less than $45,000?
	At least $45,000, but less than $55,000?
	$55,000 or more
	Don't know

7. Number and ages of children in the home


8. Please indicate the description(s) that best describe your current medical status.

	Breast cancer patient currently undergoing chemotherapy
	Breast cancer patient who finished chemotherapy
	Breast cancer patient currently undergoing radiation therapy
	Breast cancer who finished radiation therapy
	Identified at high rick for breast cancer, with no personal history of breast cancer
	No personal history of breast cancer and not identified at high risk