Survey of Health Behaviors

1

Instructions
Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/XXXX

This survey asks questions about your health and daily living. All of your
answers and insights are very valuable to us. Please read each question and set
of instructions carefully, and consider each of the answer choices before making
your selections. There are no right or wrong answers. Please mark your answers

carefully so they can be identified easily ().

Public reporting burden for this collection of information is estimated to average 40 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA
30333, ATTN: PRA (0920-XXXX).

G e n e r a l H e a lt h
1.

In general, would you say your health is:
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2.

The following questions are about activities you might do during a typical day. Does your health now
limit you in these activities? If so, how much?

a.
b.
3.

Excellent
Very good
Good
Fair
Poor

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All of the
Time

Most of
the Time

Some of
the Time

A Little of
the Time

None of
the Time

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

During the past 4 weeks, how much of the time have you had any of the following problems with your work
or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
All of the
Time

Most of
the Time

Some of
the Time

A Little of
the Time

None of
the Time

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During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
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1

No, Not Limited
at All

During the past 4 weeks, how much of the time have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?

a. Accomplished less than you would like?
b. Did work or other activities less
carefully than usual?
5.

Yes, Limited
a Little

Moderate activities, such as moving
a table, pushing a vacuum cleaner,
bowling, or playing golf
Climbing several flights of stairs

a. Accomplished less than you would like?
b. Were limited in the kind of work
or other activities?
4.

Yes, Limited
a Lot

Not at all
A little bit
Moderately
Quite a bit
Extremely

6.

These questions are about how you feel and how things have been with you during the past 4 weeks. For
each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…

a. Have you felt calm and peaceful?
b. Did you have a lot of energy?
c. Have you felt downhearted and
depressed?
7.

Most of
the Time

Some of
the Time

A Little of
the Time

None of
the Time

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During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting friends, relatives, etc.)?






8.

All of the
Time

All of the time
Most of the time
Some of the time
A little of the time
None of the time

Have you experienced any of the following medical conditions in the past year?
(Check ALL that apply)
 Arthritis
 Asthma
 Diabetes (including borderline diabetes)
 Emphysema or Chronic Obstructive Pulmonary disease (COPD)
 Kidney problems or failure
 Chronic liver condition
 Heart problems (heart attack, coronary artery/heart disease, stroke, irregular heartbeat, etc.)
 Hypertension or high blood pressure
 Depression (feeling sad or blue) that required treatment
 Anxiety (nervousness) that required treatment
 Severe problems with memory or concentration
 Osteoporosis (fragile or soft bones)
 Stomach and/or intestinal problems (Crohn’s disease, ulcers, inflammatory bowel disease, etc.)
 Other: ___________________________________________________________
 None of the above

2

9.

How harmful or beneficial do you think the following activities are for your overall health and wellbeing? (Check the answer that best applies for EVERY question)

a.
b.
c.
d.
e.

Exercise
Healthy eating habits (nutrition)
Healthy body weight
Drinking alcohol
Smoking cigarettes

Very
Harmful

Somewhat
Harmful

Neither

Somewhat
Beneficial

Very
Beneficial

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Exercise
For the next few questions on exercise, please…
• Think about your average weekly exercise in the last 3 months.
• Only count exercise that was done during free time (not during your job or housework).
• Only count exercise that lasted 10 minutes or longer.
10.

In the past 3 months, have you done any exercise in your free time?
 No (please skip to question 20)
 Yes (please continue)

LIGHT INTENSITY EXERCISE is exercise that takes minimal effort, causes very slight increases in breathing or heart
rate, and does not usually cause perspiration or sweating. EXAMPLES: easy walking, yoga, bowling, lawn bowling,
shuffleboard, golf.
11.

In the last 3 months, have you done any LIGHT INTENSITY EXERCISE that lasted at least 10 minutes or longer?
 No (please skip to question 12)
 Yes (please continue)

12.

In a typical week (7 days), on how many days do you do LIGHT INTENSITY EXERCISE for 10 minutes
or longer?
______ days per week

13.

On the days when you do LIGHT INTENSITY EXERCISE, how many times per day do you usually do it?

______ times per day (number of exercise sessions per day)

14.

When you do LIGHT INTENSITY EXERCISE, about how many minutes to you spend doing it
during each exercise session?

______ minutes per session
MODERATE INTENSITY EXERCISE causes small increases in breathing or heart rate, light perspiration or sweating, and
is not exhausting. EXAMPLES: fast walking, tennis, easy bicycling, easy swimming, dancing

3

15.

In the last 3 months, have you done any MODERATE INTENSITY EXERCISE that lasted at least
10 minutes or longer?
 No (please skip to question 16)
 Yes (please continue)

16.

In a typical week (7 days), on how many days do you do MODERATE INTENSITY EXERCISE?
(please only count exercise that lasts 10 minutes or longer)

______ days per week

17.

On the days when you do MODERATE INTENSITY EXERCISE, how many times per day do you
usually do it?

______ times per day (number of exercise sessions per day)

18.

When you do MODERATE INTENSITY EXERCISE, about how many minutes do you spend doing
it during each exercise session?

______ minutes per session
VIGOROUS INTENSITY EXERCISE is hard effort exercise that causes large increases in breathing or heart rate and
perspiration or sweating. EXAMPLES: running, aerobics classes, cross country skiing, vigorous swimming, vigorous
bicycling

19.

In the last 3 months, have you done any VIGOROUS INTENSITY EXERCISE that lasted at least 10
minutes or longer?
 No (please skip to question 20)
 Yes (please continue)

20.

In a typical week (7 days), on how many days do you do VIGOROUS INTENSITY EXERCISE?
(please only count exercise that lasts 10 minutes or longer)

______ days per week

21.

On the days when you do VIGOROUS INTENSITY EXERCISE, how many times per day do you
usually do it?

______ times per day (number of exercise sessions per day)

22.

When you do VIGOROUS INTENSITY EXERCISE, about how many minutes do you spend doing
it during each exercise session?

______ minutes per session

23.

Since you completed treatment for colon or rectal cancer, has there ever been a time you thought you
were not getting as much exercise each week as you should?
 No
 Yes
4

24.

How strongly do you AGREE or DISAGREE with each of the following statements about doing
regular exercise? (Check the answer that best applies for EVERY question)

Exercise…
a. is very difficult or tiring
b. is painful
c. makes me look good
d. is inconvenient or difficult to arrange
e. increases my chances of living
a long life
f. makes me feel good
g. reduces my chances of getting
cancer again
h. may cause injury or harm to my
body
i. costs me too much money
j. is important for my health
25.

Strongly
Disagree

Somewhat
Disagree

Neither
Agree Nor
Disagree

Somewhat
Agree

Strongly
Agree

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How familiar are you with the following statement? (Check the answer that best applies)
Never Heard
of it

Slightly
Familiar

Mostly
Familiar

Very
Familiar

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Adults should do 30 minutes or more
of moderate-intensity physical activity
on 5 or more days of the week.
26.

How much do you agree or disagree with the following statement? (Check the answer that best applies)
Strongly Somewhat Neither Somewhat
Disagree Disagree Agree Nor
Agree
Disagree
Close friends and family members
think it’s important that I get regular
exercise

27.

5







Strongly
Agree





How confident are you in your ability to exercise on a regular basis?
(Check the answer that best applies)
Not at all Confident

Slightly Confident

Moderately Confident

Mostly Confident

Totally Confident



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Nutrition
28.

Below is a list of dietary recommendations. Please tell us how familiar you are with each
recommendation. Do NOT answer whether you follow the recommendation but rather how well you
know the recommendation. (Check one answer for EVERY recommendation)
Never Heard
Slightly Familiar Mostly Familiar
Very Familiar
of This
With This
With This
With This
Recommendation Recommendation Recommendation Recommendation
VEGETABLE SUBGROUPS: (1) dark green, (2) orange, (3) legumes, (4) starchy, and (5) other vegetables
Eat vegetables from all five
vegetable subgroups several




times each week
Eat approximately 2½ cups of
vegetables and 2 cups of fruits

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

each day, depending on your
daily calorie needs
WHOLE GRAINS contain the entire grain kernel. EXAMPLES include whole-wheat flour, bulgur (cracked wheat),
oatmeal, whole cornmeal, brown rice. 1 ounce is equal to 1 slice whole grain bread, 1 cup ready-to-eat
breakfast cereal, ½ cup cooked brown rice, etc.
Eat at least 3 ounces of whole

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

grain products each day
EXAMPLES OF REFINED CARBOHYDRATES AND SUGARS: pastries, sweetened cereals, soft drinks, and sugars
Limit intake of refined




carbohydrates and sugars
Keep total fat intake between
20% to 35% of your total

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
calories each day
SATURATED AND TRANSFATS exist in commercially fried and baked foods such as french fries, doughnuts, cookies,
crackers, muffins, pies and cakes
Limit saturated and trans fats
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EXAMPLES OF PROCESSED MEATS: salami, hot dogs, deli meats, ham, sausage
Limit intake of processed
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
meats
When selecting and preparing
meat, poultry, dry beans, and
milk or milk products, make

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
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choices that are lean,
low-fat, or fat-free
DEFINITION OF A DRINK: 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits
Limit alcohol drinking to no
more than 2 drinks per day for




men and 1 drink per day for
women.
6

29.

Think about the kinds of foods you usually eat and answer the following questions about your eating
habits. (Check one answer for EVERY question)

How often do you…
a. include vegetables and fruits at
every meal and for snacks?
b. eat foods that have saturated fat
or trans fat in them?
c. choose whole grains (brown
rice, whole grain bread) instead
of processed or refined grains
(white rice, white bread)?
d. eat processed meats?
e. choose to eat fish, poultry,
or beans instead of beef, pork,
or lamb?
f. eat a variety of vegetables and
fruits each day?
g. select meat, poultry, dry beans,
milk and milk products that are
lean, low-fat, or fat free?

30.

Most of
the Time

Sometimes

Rarely

Never

Don’t Know
or Not Sure

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Since you finished treatment for colon or rectal cancer, has there ever been a time when you thought
your diet was not as healthy as it should have been?
 No
 Yes

7

Always

31.

How strongly do you AGREE or DISAGREE with each of the following statements about eating a
healthy diet? (Check one answer for EVERY question)

Eating a healthy diet…
a. means that I’m limited to eating
foods I don’t like
b. makes me feel good
c. takes too much effort
d. upsets my stomach
e. may cause injury or harm to my body
f. increases my chances of living
a long life
g. is important for my health
h. costs me too much money
i. reduces my chances of getting cancer
again
j. makes me look good

32.

Somewhat
Disagree

Neither
Agree Nor
Disagree

Somewhat
Agree

Strongly
Agree

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How much do you agree or disagree with the following statement?
(Check the answer that best applies)

Close friends and family members
think it’s important that I eat a
healthy diet

33.

Strongly
Disagree

Strongly
Disagree

Somewhat
Disagree





Neither Agree Somewhat
Nor Disagree
Agree



Strongly
Agree





How confident are you in your ability to eat a healthy diet?
(Check the answer that best applies)
Not at all Confident

Slightly Confident

Moderately Confident

Mostly Confident

Totally Confident

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8

W e igh t
34.

Since you completed treatment for colon or rectal cancer, have you ever worked on losing weight or
maintaining your weight for health reasons?
 No
 Yes

35.

About how tall are you without shoes?

______ Feet ______ Inches

36.

About how much do you weigh without shoes?

______ Pounds

37.

Which of the following best describes your current body weight?
(Check the ONE that best applies)
 Underweight
 Normal or healthy weight
 Overweight
 Extremely overweight or obese

38.

How strongly do you AGREE or DISAGREE with each of the following statements about achieving or
maintaining a healthy weight? (Check one answer for EVERY question)

Achieving or maintaining a healthy weight…
a. means that I can’t live the way
I want to
b. makes me feel good
c. may cause injury or harm to
my body
d. takes too much time and attention
e. is unpleasant or uncomfortable
f. reduces my chances of getting cancer
again
g. makes me look good
h. costs me too much money
i. is important for my health

9

Strongly
Disagree

Somewhat
Disagree

Neither
Agree Nor
Disagree

Somewhat
Agree

Strongly
Agree

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39.

How much do you AGREE or DISAGREE with the following statement?
(Check the answer that best applies)

Close friends and family members
think it’s important
that I achieve or maintain a healthy
weight
40.

Strongly
Disagree

Somewhat
Disagree





Neither Agree Somewhat
Nor Disagree
Agree



Strongly
Agree





How confident are you in your ability to achieve or maintain a healthy weight?
(Check the answer that best applies)
Not at all Confident

Slightly Confident

Moderately Confident

Mostly Confident

Totally Confident

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Tobacco
41.

When you were first diagnosed with colon or rectal cancer, did you smoke cigarettes: (Check one)
 Not at all
 Some days
 Every day

42.

Do you now smoke cigarettes: (Check one)
 Not at all
 Some days
 Every day

43.

Since you were first diagnosed with colon or rectal cancer, have you stopped smoking for one day or
longer because you were trying to quit smoking? (Check the ONE that best applies)
 I did not smoke when I was diagnosed, and I do not smoke now
 No
 Yes

44.

How much do you agree or disagree with the following statement?
(Check the answer that best applies)

Close friends and family members
think it’s important that I avoid
smoking

Strongly
Disagree

Somewhat
Disagree





Neither Agree Somewhat
Nor Disagree
Agree





Strongly
Agree


10

45.

How confident are you in your ability to avoid smoking?
(Check the answer that best applies)
Not at all Confident

Slightly Confident

Moderately Confident

Mostly Confident

Totally Confident

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Alcohol
The next few questions are about alcohol drinking. For these questions, keep in mind that one drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor.
46.

During the past 30 days, on how many days did you have at least 1 drink of any alcoholic beverage such
as beer, wine, a malt beverage or liquor? (Check one)
 0 days (Skip to question 40)
 1 or more days On how many days did you have 1 or more drinks? ______ (Answer 1–30)

47.

During the past month, on the days when you drank, about how many drinks did you drink on average?

______ Number of drinks

48.

Compared to when you were diagnosed with colon or rectal cancer, do you now drink alcohol:
(Check the ONE that best applies)
 Less
 The same amount
 More
 I did not drink when I was diagnosed and I do not drink now

Note: If you answered “less” to the last question, please continue with question 40. Otherwise, please skip to
question 41.
49.

Which of the following reasons explain why you drink less alcohol now than you did when you were
diagnosed with colon or rectal cancer? (Check ALL that apply)
 For my physical health
 For weight control
 I was told I drank too much
 For my mental health
 For financial or job reasons
 For social or relationship reasons
 For religious or spiritual reasons
 No reason
 Other: ___________________________________________________________

11

50.

How much do you agree or disagree with the following statement? (Check the answer that best applies)

Close friends and family members
think it’s important that I limit or
avoid drinking alcohol
51.

Strongly
Disagree

Somewhat
Disagree





Neither Agree Somewhat
Nor Disagree
Agree



Strongly
Agree





How confident are you in your ability to limit or avoid drinking alcohol?
(Check the answer that best applies)
Not at all Confident

Slightly Confident

Moderately Confident

Mostly Confident

Totally Confident

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Your Comments
52.

What is the biggest challenge to living a healthy lifestyle for you now?

12

R e c o m m e n dat i o n s
The next few questions are about health-related lifestyle behaviors that health care providers might have
mentioned or recommended to you. Please do NOT answer whether you do or do not practice the behaviors, but
answer whether your doctor or health care provider has talked with you about the behaviors.
53.

Since you finished treatment for colon or rectal cancer, has a doctor, nurse, or other health care provider
ever talked with you about any of the following behaviors?
(Check the answer that best applies for EVERY question)

a. Getting regular exercise
b. Having healthy (nutritious) eating
habits
c. Limiting or avoiding alcohol
d. Taking vitamins or supplements
e. Taking aspirin
f. Not smoking cigarettes
g. Having a healthy bodyweight
h. Learning more about your cancer
i. Reducing stress in your life
j. Getting the support you need from
others
k. Caring for your mental or
emotional health

13

NO,
a Healthcare
Provider Has NOT
Talked With Me
About This

YES,
a Healthcare
Provider Has
Talked With Me
About This

Don’t Know (DK)
or Can’t Remember
if a Healthcare
Provider Talked With
Me About This

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H e a lt h H i s t o r y
54.

What was your age when you were first diagnosed with colon or rectal cancer?

________ years

55.

Which of the following statements best describes how you were diagnosed with colon or rectal cancer
for the first time? (Check ONE)
 I was diagnosed as part of routine exams (check-ups) or screening tests (NOT because of symptoms
or problems I was having).
 I was diagnosed after seeking medical care to check on problems or symptoms I was having.

56.

Did you ever receive any of these treatments for colon or rectal cancer?
(Check NO or YES for every treatment)
Surgery to remove the cancer
 No
 Yes
Chemotherapy
 No
 Yes
Radiation therapy
 No
 Yes
Other: _________________________________
 No
 Yes

57.

Have you moved (changed homes) since you were first treated for colon or rectal cancer?
 No
 Yes

If you answered YES, about how far is your current home from the
home where you lived when you were first treated? (Check ONE)
 50 miles or less
 More than 50 miles

14

58.

How strongly do you AGREE or DISAGREE with each of the following statements about the care you
received for your colon or rectal cancer? (Please check one box for EVERY statement)
Strongly
Disagree
a. The doctors were good about explaining
my diagnosis and the plans for my cancer
treatments.
b. I think my doctor’s office had everything
needed to provide complete cancer care.
c. The cancer care I received was just about
perfect.
d. Sometimes I wondered if the doctor’s
decisions about my treatment were
correct.
e. I was sure that I could get the cancer
care I needed without being set back
financially.
f. The doctors were careful to check
everything when treating and examining
me.
g. I had to pay for more of my cancer care
than I could afford.
h. I had easy access to the cancer specialists
(cancer doctors, oncologists) I needed.
i. Where I got cancer care, people had to
wait too long for emergency treatment.
j.
k.
l.
m.
n.
o.

The doctors treated me in a very friendly
and courteous manner.
The people providing my cancer care
sometimes hurried too much when they
treated me.
The doctors sometimes ignored (did not
listen to) what I told them.
I had some doubts about the ability of the
doctors who treated me.
The doctors usually spent plenty of time
with me.
I found it hard to get an appointment for
the cancer care I needed right away.

p. I was dissatisfied (unhappy) with some
things about the cancer care I received.
q. I was able to get cancer care whenever I
needed it.
15

Disagree Uncertain

Agree

Strongly
Agree

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59.

Do you have any friends or family members that you talk to about your health?
 No
 Yes

How often do you talk to these friends or family members
about health?





Not very often
Occassionally
Somewhat often
Very often

Recurrence
60.

Since you were first diagnosed and treated for colon or rectal cancer, has a doctor ever told you that you
had a colon or rectal cancer recurrence (the cancer came back)?
 No
 Yes

61.

What was your age when your cancer came back (recurred)?
____ years

Other than colon or rectal cancer, has a doctor or other health professional ever diagnosed you with
cancer of any kind?
 No
 Yes
If you answered YES, check ALL the other cancers that you have

had below and write in your age when you were first diagnosed

with each cancer.












62.

Bladder cancer
Breast cancer
Cervical cancer
Kidney cancer
Lung cancer
Non-Hodgkin Lymphoma
Prostate cancer
Skin (melanoma) cancer
Skin (non-melanoma) cancer
Stomach cancer
Other: ____________________

age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old
age at diagnosis: ____ years old

Currently, are you receiving any treatments for any type of cancer (e.g., chemotherapy, hormone pill)?
 No
 Yes

If you answered YES, please explain:

16

The next few questions ask about your thoughts and feelings about getting cancer again. When you answer
them, be as honest as you can. There are no right or wrong answers. Simply give your answers as you feel
right now.
63.

How would you rate your chances of getting cancer of the colon or rectum again in the future (i.e.,
recurrence)? (Check the ONE that best applies)
 Very low
 Somewhat low
 Moderate
 Somewhat high
 Very high

64.

How would you rate your chances of getting cancer of the colon or rectum again compared with people
your age who have had a similar history of cancer? (Check the ONE that best applies)
 Much lower
 Lower
 The same
 Higher
 Much higher

65.

How would you rate your chances of getting another type of cancer in the future?
(Check the ONE that best applies)
 Very low
 Somewhat low
 Moderate
 Somewhat high
 Very high

66.

How would you rate your chances of getting cancer in the future, compared with people your age who
never have had cancer? (Check the ONE that best applies)
 Much lower
 Lower
 The same
 Higher
 Much higher

67.

How often do you worry about getting cancer again?
(Check the ONE that best applies)
 Never
 Rarely or never
 Sometimes
 Often
 All the time

17

68.

How severely would getting cancer again disrupt your physical comfort?
(Check the box that best applies)
Not at all Disruptive


69.

Very Disruptive






How severely would getting cancer again disrupt your emotional well-being?
(Check the box that best applies)
Not at all Disruptive


70.

Very Disruptive




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

Very Disruptive








Overall, how disruptive would getting cancer again be in your life?
(Check the box that best applies)
Not at all Disruptive


72.



How severely would getting cancer again disrupt your physical attractiveness and appearance?
(Check the box that best applies)
Not at all Disruptive

71.



Very Disruptive








How severe would the health consequences of getting cancer again be for you?
(Check the box that best applies)
Not at all Disruptive








Very Disruptive


Routine Visits
73.

What type of health care coverage or insurance do you currently use to pay for most of your medical
care? (Check ALL that apply)










Don’t have health care coverage
Medicare plus other insurance
Medicare only (no other insurance)
Your employer’s (or former employer’s) insurance plan
Someone else’s employer’s (or former employer’s) insurance plan
A plan that you or someone else buys on your own
Medicaid or Medical Assistance
The military, Tri-Care, CHAMPUS, or the VA
Some other source

18

74.

Since you finished treatment for your colon or rectal cancer, who have you typically seen for routine
check-ups? (Check ALL that apply)






75.

A primary care doctor
An oncologist (cancer doctor)
A gastroenterologist (doctor that examines the stomach and intestines and does colonoscopy)
Other: ____________________________________________________________________
I have not seen any doctor on a regular basis

Since you finished treatment for colon or rectal cancer, have you ever received advice from a doctor,
nurse, or other health professional about how often you should return for routine check-ups?
 No
 Don’t know/not sure
 Yes
If you answered YES, was this advice written or printed on paper

for you (for example, in a care plan or appointment card)?

76.

About how long has it been since you last visited a doctor for a routine check-up?
(Check the ONE that best applies)







77.

Within the past 6 months
Within the past 7 to 12 months
Within the past 1 to 2 years (at least 1 year ago but less than 2 years ago)
2 or more years ago
I have never had a routine check-up
Don’t know/not sure

As far as you know, when are you due for your next routine check-up?
(Check the ONE that best applies)







78.

Within the next 6 months
Within the next 7 to 12 months
Within the next 13 months to 2 years
In more than 2 from now
Never (will not have another follow-up visit)
Don’t know/not sure

Since you finished treatment for colon or rectal cancer, has there ever been a time when you were
supposed to go in for a routine check-up but did not?
 No
 Yes

19

 No
 Yes

79.

How strongly do you AGREE or DISAGREE with each of the following statements about getting
routine check-ups? (Check one box for EVERY statement)
Strongly Somewhat Neither Somewhat Strongly
Disagree Disgree Agree Nor
Agree
Agree
Disagree
Getting routine check-ups…
a. is reassuring (makes me feel better).
b. is inconvenient or difficult to arrange.
c. reduces my chances of getting cancer
again.
d. costs me too much money.
e. is harmful.
f. increases my chances of living a long life.
g. is important for my health.
h. makes me worry that I’ll find out
something is wrong.
i. takes too much time.

80.

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

How much do you agree or disagree with the following statement?
(Check the answer that best applies)
Strongly Somewhat Neither Somewhat Strongly
Disagree Disgree Agree Nor
Agree
Agree
Disagree
Close friends and family members think it’s
important that I go in for routine check-ups

81.











How confident are you that you can keep/attend your routine check-up appointments as scheduled?
(Check the answer that best applies)
Not at all confident

Slightly confident

Moderately confident

Mostly confident

Totally confident











20

Colonoscopy
Colonoscopy is an exam in which a tube is inserted in the rectum to view the entire colon for signs of cancer and other
health problems. Before a colonoscopy is done, you are usually given medication through a needle in your arm to
make you sleepy.
82.

Since you finished treatment for colon or rectal cancer, have you ever received a recommendation from
a doctor, nurse, or other health professional about when you should return for a colonoscopy?
 No
 Don’t know/not sure
 Yes
If you answered YES, was this advice written or printed on paper

for you, for example in a care plan or appointment card?

83.

Since you finished treatment for colon or rectal cancer, about how many colonoscopies have you had?
(Check the ONE that best applies)





84.

Within the past year (anytime less than 12 months ago)
Within the past 1 to 2 years (at least 1 year ago but less than 2 years ago)
Within the past 2 to 3 years (at least 2 years ago but less than 3 years ago)
Within the past 3 to 4 years (at least 3 years ago but less than 4 years ago)
4 or more years ago
I have never had a colonoscopy
Don’t know/not sure

As far as you know, when are you due for your next colonoscopy? (Check the ONE that best applies)







21

None (0) since completing treatment
1 or 2 since completing treatment
3 or more since completing treatment
Don’t know/not sure

How long has it been since you had your last colonoscopy? (Check the ONE that best applies)








85.

 No
 Yes

Within the next year (anytime less than 12 months from now)
Within the next 1 to 2 years (at least 1 year from now but less than 2 years from now)
Within the next 2 to 5 years (at least 2 years from now but less than 5 years from now)
5 or more years from now
Never (will not have colonoscopy again)
Don’t know/not sure

86.

Since you finished treatment for colon or rectal cancer, has there ever been a time when you were
supposed to go in for a colonoscopy but did not?
 No
 Yes

87.

How strongly do you AGREE or DISAGREE with each of the following statements about getting
colonoscopies to screen for cancer recurrence. (Check one answer for EVERY question)
Strongly Somewhat Neither Somewhat
Disagree Disgree Agree Nor
Agree
Disagree
Getting a colonoscopy…
a. is inconvenient or difficult to arrange
b. is harmful
c. reduces my chances of getting cancer
again
d. is reassuring (makes me feel better)
e. increases my chances of living a long life
f. takes too much time
g. makes me worry that I’ll find out
something is wrong
h. costs me too much money

88.


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

How much do you agree or disagree with the following statement? (Check the answer that best applies)
Strongly Somewhat Neither Somewhat
Disagree Disgree Agree Nor
Agree
Disagree
Close friends and family members think it’s
important that I undergo regular screening by
colonoscopy

89.

Strongly
Agree







Strongly
Agree





How confident are you that you can attend a scheduled colonoscopy when it is recommended?
(Check the answer that best applies)
Not at all confident

Slightly confident

Moderately confident

Mostly confident

Totally confident











22

CEA T e s t i n g
Carcinoembryonic Antigen (or CEA) is a substance in the blood of some people with colon cancer. After surgery and
other treatments are finished, CEA blood tests are used to look for early warning signs that cancer has come back.
90.

Since you finshed treatment for colon or rectal cancer, have you ever received advice from a doctor,
nurse, or other health professional about when you should return for CEA blood tests?
 No
 Don’t know/not sure
 Yes
If you answered YES, was this advice written or printed on paper for you, for

example in a care plan or appointment card?

 No
 Yes

Your Comments
91.

23

What, if anything, has made it most difficult for you to get medical follow-up care since you finished
treatment for colon or rectal cancer?

Mammogram
Note: If you are a man, please skip to question 97. If you are a woman, please continue with question 92.

A mammogram is an x-ray of each breast to look for breast cancer.
92.

Since you finished treatment for colon or rectal cancer, has a doctor, nurse, or other health professional
ever recommended that you get a mammogram to screen for breast cancer?
 No
 Don’t know/not sure
 Yes
If you answered YES, was this advice written or printed on paper

for you, for example in a care plan or appointment card?

93.

 No
 Yes

How long has it been since you had your last mammogram? (Check the ONE that best applies)






Within the past year (anytime less than 12 months ago)
Within the past 1 to 2 years (at least 1 year ago but less than 2 years ago)
2 or more years ago
I have never had a mammogram
Don’t know/not sure

Pap Testing
A Pap test is a test for cancer of the cervix.
94.

Since you finished treatment for colon or rectal cancer, has a doctor, nurse, or other health professional
ever recommended that you get a Pap test to screen for cervical cancer?
 No
 Don’t know/not sure
 Yes
If you answered YES, was this advice written or printed on paper

for you, for example in a care plan or appointment card?

95.

 No
 Yes

How long has it been since your last Pap test? (Check the ONE that best applies)






Within the past year (anytime less than 12 months ago)
Within the past 1 to 3 years (at least 1 year ago but less than 3 years ago)
3 or more years ago
I have never had a Pap test
Don’t know/not sure
24

96.

A hysterectomy is an operation to remove the uterus (womb). Have you had a hysterectomy?
 No
 Don’t know/not sure
 Yes

PSA /DRE T e s t i n g
To check men for prostate cancer, two different tests are commonly used. One test, called a Prostate-Specific Antigen
(PSA) test, is a blood test that measures the level of prostate-specific antigen, a substance produced by the prostate.
Another test, called a Digital Rectal Exam (DRE), is an exam in which a doctor, nurse, or other health professional
places a gloved finger into the rectum to feel the size, shape, and hardness of the prostate gland.
Note: If you are a woman, please skip to question 105. If you are a man, please continue with question 97.
97.

Since you finished treatment for colon or rectal cancer, has a doctor, nurse, or other health care provider
ever talked with you about getting screened for prostate cancer by having a PSA test or DRE exam?
 No
 Don’t know/not sure
 Yes
If you answered YES, which of the following statements best describes your

health care provider’s advice? (Check ALL that apply)













98.

How long has it been since you had your most recent PSA test or DRE exam to check for prostate
cancer? (Check the ONE that best applies)






25

that you should have a PSA test
that you should have a DRE exam
that you should NOT have a PSA test
that you should NOT have a DRE exam
your health care provider did not make a recommendation
about either the DRE exam or the PSA test
your health care provider did not make a recommendation about the
DRE exam

Within the past year (anytime less than 12 months ago)
Within the past 1 to 2 years (at least 1 year ago but less than 2 years ago)
2 or more years ago
I have never had either of these tests/exams
Don’t know/not sure

99.

Since you finished treatment for colon or rectal cancer, has there ever been a time when you were
advised to get screened for prostate cancer, but did not?
 No
 Yes

100. Would you say your risk of getting prostate cancer in the future is low, medium, or high?
(Check the ONE that best applies)





Low
Medium
High
Don’t know/not sure

101. How would you rate your chances of getting prostate cancer in the future, compared with people your
age who never have had cancer? (Check the ONE that best applies)






Much lower
Lower
The same
Higher
Much higher

102. How strongly do you AGREE or DISAGREE with each of the following statements about getting
screened for prostate cancer? (Check the number that best applies for EVERY question)
Strongly Somewhat Neither Somewhat
Disagree Disgree Agree Nor
Agree
Disagree
Getting screened for prostate cancer…
a. is painful or embarrassing
b. is reassuring (makes me feel better)
c. is inconvenient or difficult to arrange
d. is important for my health
e. makes me worry I’ll find out something
is wrong
f. takes too much time
g. costs me too much money
h. increases my chances of living a long life
i. reduces my chances of getting prostate
cancer

Strongly
Agree







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
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26

103. How much do you agree or disagree with the following statement: (Check the answer that best applies)
Strongly Somewhat Neither Somewhat
Disagree Disgree Agree Nor
Agree
Disagree
Close friends and family members think
it’s important that I be screened for prostate
cancer







Strongly
Agree





104. How confident are you that you can get screened for prostate cancer?
(Check the answer that best applies)
Not at all confident

Slightly confident

Moderately confident

Mostly confident

Totally confident











About You
105. What is today’s date?
Month

Day

Year

106. In what month and year were you born?

Month

Year

107. What is your gender? (Check ONE)
 Male
 Female
108. Are you Hispanic or Latino? (Check ONE)
 Yes
 No
109. Which of the following would you say is your race? (Check ONE)





27

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

110. Are you? (Check ONE)
 Married
 Divorced
 Widowed
 Separated
 Never married
 Member of an unmarried couple
111. Please check the highest level of school you completed:
(Check the ONE that best applies)
 Never attended school or only attended kindergarten
 Grades 1 through 8 (elementary)
 Grades 9 through 11 (some high school)
 Grade 12 or GED (high school graduate)
 College 1 year to 3 years (some college or technical school)
 College 4 years or more (e.g., college graduate, bachelor’s, BA, BS)
 Graduate degree (e.g., master’s, doctorate, MD, JD, PhD)
 Don’t know
 Refused
112. Are you currently? (Check the one that best applies)
 Retired
 Employed for wages
 Self-employed
 A homemaker
 Unable to work or out of work
113. Has anyone helped you complete this survey?
 No
 Yes

If you answered YES, who helped you? (Check ALL that apply)
 Spouse or partner
 Friend or relative
 Health care professional
 Other, please explain: ____________________________

28

Your Comments
114. Who or what has motivated you the most to take action to improve your health after cancer?

115. What could help you live a healthier lifestyle now, as a cancer survivor?

116. Any other comments?

29

Thank You
Thank you for completing this survey. We appreciate your time. Please mail your completed survey in the envelope
provided to:
Macro International Inc.
Attention: Survey of Health Behaviors
126 College Street
Burlington, VT 05401
Please check the box below if you would like to receive information about the results of this study after data
collection is complete. You also may find more information about cancer survivorship and CDC’s survivorship
activities at www.cdc.gov/cancer/survivorship/.
 Yes, I would like study results mailed to me

30

31