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  2. 2016
  3. March
  4. N
  5. NTM 3250 proposal survey
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Questions marked with a * are required Exit Survey
 
 
What is your gender?
 
Male
 
Female
 
 
 
* Which medical imaging scans were used to diagnose your ailment? (Choose all that apply.)
 
Computed Tomography (CT)
 
Magnetic Resonance Imaging (MRI)
 
Positron Emission Tomography (PET)
 
X-Ray/Mammography
 
Ultra Sound

 
 
 
How much did you pay out of pocket for your last medical scan?
 
$100 - $299
 
$300 - $499
 
$500 -$699
 
$700+
 
Less than $100/ Nothing
 
 
 
In what part of your body was cancer located? (Choose all that apply.)
 
Lung
 
Breast
 
Colon
 
Prostate
 
Stomach
 
Other

 
 
 
How comfortable was your last Scan?
Extremely Uncomfortable
Uncomfortable
Neutral
Comfortable
Extremely Comfortable
 
 
 
* How many people in your immediate family have been diagnosed with any type of cancer?
 
0 – 2
 
3 – 4
 
4 – 5
 
5 – 6
 
7+
 
 
 
* Of those immediate family members, including yourself, how many of them were diagnosed with cancer via a preventative scan?
 
0 – 2
 
3 – 4
 
4 – 5
 
5 – 6
 
7+