Psychosocial Oncology Program
Albert Einstein Cancer Center Montefiore Medical Center

Tell us about Yourself

In order to better serve the community it would help us if we get to know you

Just click on answers.

Have you ever had a cancer screening?
Yes         No

If so, what kind of screening? (click on more than one answer if you have had more than one test):
Mammography    Pap Test    Sigmoidoscopy    Hemocult    PSA testing   

Do you currently smoke?
Yes         No

Do you want to quit smoking?
Yes         No

Do you know anybody with cancer?
Friends    Myself    Family   

Are you:
Male        Female

What level of schooling have you completed:
No official schooling
Elementary school
High School
Vocational School
Graduate School

How old are you?

Where do you live (enter zip code):

Do you have medical insurance?
Yes         No

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