Form 1 Main Study - Cycle 1 Instrument

OMB # 0925-0538
Expiration Date: XX/XX/XXXX

START HERE:

1.

Is there more than one person age 18 or older living in this household?
Yes
No

GO TO A1 on the next page

2.

Including yourself, how many people age 18 or older live in this household?

3.

The adult with the next birthday should complete this questionnaire. This way, across all
households, HINTS will include responses from adults of all ages.

4.

Please write the first name, nickname or initials of the adult with the next birthday. This is the
person who should complete the questionnaire.

Si prefiere recibir la encuesta en español, por favor llame 1-888-738-6812

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42
USC 285a-1.a and 285a1.3). The purpose of this data collection is to find out the public’s health information seeking behaviors. The results of the data
collection will be used to improve the survey instrument. Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary,
and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way.
The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project. The
report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 30
minutes per response, including the 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0920-0538). Do not return the completed form to this address.

1

A: Looking For Health Information
A1. Have you ever looked for information about
health or medical topics from any source?
Yes
No

A4. Based on the results of your most recent
search for information about health or
medical topics, how much do you agree or
disagree with each of the following
statements?

GO TO A6 in the next column

A2. The most recent time you looked for
information about health or medical topics,
where did you go first?
MarkX only one.

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner

A3. The most recent time you looked for
information about health or medical topics,
who was it for?
Myself
Someone else
Both myself and someone else

a. It took a lot of effort to get the
information you needed ............................
b. You felt frustrated during your
search for the information.........................
c.

You were concerned about the
quality of the information ..........................

d. The information you found was
hard to understand ................................

A5. Overall, how confident are you that you
could get advice or information about
health or medical topics if you needed it?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

A6. In general, how much would you trust
information about health or medical topics
from each of the following?

a. A doctor ....................................................
b. Family or friends ................................
c.

Newspapers or magazines .......................

d. Radio ........................................................
e. Internet .....................................................
f.

Television .................................................

g. Government health agencies ...................
h. Charitable organizations ...........................
i.

Religious organizations and
leaders ......................................................

2

A7. Imagine that you had a strong need to get
information about health or medical topics.
Where would you go first?
Mark X only one.
Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner
Other-Specify

B: Using the Internet to Find Information
B1. Do you ever go on-line to access the
Internet or World Wide Web, or to send
and receive e-mail?
Yes
No

GO TO B4 on the next page

B2. When you use the Internet, do you access
it through...
Yes No

a. A regular dial-up telephone line ...............
b. Broadband such as DSL, cable or FiOS ..
c.

A cellular network (i.e., phone, 3G/4G) ....

d. A wireless network (Wi-Fi) .......................

A8. Have you ever looked for information about
cancer from any source?
Yes
No

A9. In the past 12 months, have you used the
Internet to look for information about
cancer for yourself?
Yes
No

B3. How often do you access the Internet
through each of the following?

a. Computer at home................................
b. Computer at work ................................
c.

Computer at school ................................

d. Computer in a public place
(library, community center,
other) ........................................................
e. On a mobile device (cell
phone/smart phone/tablet) .......................
f.

On a gaming device/ “Smart
TV” ............................................................

3

B4. In the past 12 months, have you used a
computer, smartphone, or other electronic
means to do any of the following…
Yes No

a. Looked for health or medical information
for yourself ...............................................

Yes No

a. Helped you track progress on a healthrelated goal such as quitting smoking,
losing weight, or increasing physical
activity? ....................................................
b. Helped you make a decision about how
to treat an illness or condition? ................

b. Looked for health or medical information
for someone else......................................
c.

B7. Has your tablet or smartphone…

c.

Bought medicine or vitamins online .........

Helped you in discussions with your
health care provider? ...............................

d. Looked for a health care provider ............
e. Used e-mail or the Internet to
communicate with a doctor or a doctor’s
office .........................................................
f.

B8. Other than a tablet or smartphone, have
you used an electronic device to monitor or
track your health within the last 12 months?
Examples include Fitbit, blood glucose
meters, and blood pressure monitors.

Made appointments with a health care
provider ....................................................

g. Securely message health care provider
and staff (e.g., e-mail) ..............................

Yes
No

h. Track health care charges and costs .......
i.

Filled out forms or paperwork related to
your health care .......................................

j.

Look up test results ..................................

B5. Please indicate if you have each of the
following.

B9. Have you shared health information from
either an electronic monitoring device or
smartphone with a health professional
within the last 12 months?
Yes
No
Not Applicable

Yes No

a. Tablet computer like an iPad, Samsung
Galaxy, Motorola Xoom, or Kindle Fire ....
b. Smartphone, such as an iPhone,
Android, Blackberry, or Windows phone ..
c.

Basic cell phone only ...............................

B10. Sometimes people use the Internet to
connect with other people online through
social networks like Facebook or Twitter.
This is often called “social media”.
In the last 12 months, have you used the
Internet for any of the following reasons?

B6. On your tablet or smartphone, do you have
any “apps” related to health and wellness?
Yes
No
Don’t know
Do not have a tablet
or smartphone
GO TO B8 in the
next column

Yes No

a. To visit a social networking site, such as
Facebook or LinkedIn ...............................
b. To share health information on social
networking sites, such as Facebook or
Twitter .......................................................
c.

To write in an online diary or blog
(i.e., Web log) ...........................................

d. To participate in an online forum or
support group for people with a similar
health or medical issue ............................
e. To watch a health-related video on
YouTube ...................................................

4

B11. Have you sent or received a text message
from a doctor or other healthcare
professional within the last 12 months?
Yes
No
Don’t know

C: Your Health Care
C1. Not including psychiatrists and other
mental health professionals, is there a
particular doctor, nurse, or other health
professional that you see most often?
Yes
No

C2. Are you currently covered by any of the
following types of health insurance or
health coverage plans?
Yes No

a. Insurance through a current or former
employer or union ....................................
b. Insurance purchased directly from an
insurance company ..................................
c.

C3. About how long has it been since you last
visited a doctor for a routine checkup? A
routine checkup is a general physical
exam, not an exam for a specific injury,
illness, or condition.
Within the past year
1-2 years ago
3-5 years ago
More than 5 years ago
Never
Don't know

C4. In the past 12 months, not counting times
you went to an emergency room, how
many times did you go to a doctor, nurse,
or other health professional to get care for
yourself?
None
GO TO D1 on the next page
1 time
2 times
3 times
4 times
5-9 times
10 or more times

Medicare, for people 65 and older, or
people with certain disabilities .................

d. Medicaid, Medical Assistance, or any
kind of government-assistance plan for
those with low incomes or a disability ......
e. TRICARE or other military health care.....
f.

VA (including those who have ever used
or enrolled for VA health care) .................

g. Indian Health Service ...............................
h. Any other type of health insurance or
health coverage plan (specify) .................

5

C5. The following questions are about your
communication with all doctors, nurses, or
other health professionals you saw during
the past 12 months.
How often did they do
each of the following?
a. Give you the chance to ask all
the health-related questions you
had ...........................................................
b. Give the attention you needed to
your feelings and emotions ......................
c.

Involve you in decisions about
your health care as much as you
wanted ......................................................

C7. In the past 12 months, when getting care
for a medical problem, was there a time
when you...
Yes No

a. Had to bring an X-ray, MRI, or other type
of test result with you to the
appointment?............................................
b. Had to wait for test results longer than
you thought reasonable? ..........................
c.

Had to redo a test or procedure because
the earlier test results were not
available? .................................................

d. Had to provide your medical history
again because your chart could not be
found? ......................................................

d. Make sure you understood the
things you needed to do to take
care of your health ................................
e. Explain things in a way you
could understand................................
f.

Spend enough time with you ....................

g. Help you deal with feelings of
uncertainty about your health or
health care ...............................................

C6. Overall, how would you rate the quality of
health care you received in the past 12
months?
Excellent
Very good
Good
Fair
Poor

D: Medical Records
Next, we are going to ask you some questions
on medical records. Medical records are defined
as medical history, such as laboratory test
results, clinical notes, and current list of
medications.
D1. Do any of your doctors or other health care
providers maintain your medical
information in a computerized system?
Yes
No
Don’t Know

D2. Have you ever been offered online access
to your medical record by your…
Don’t
Yes No Know

a. health care provider?................................
b. health insurer? ..........................................

D3. Did any of your health care providers,
including doctors, nurses, or office staff
encourage you to use an online medical
record?
Yes
No

6

D4. How many times did you access your
online medical record in the last 12
months?
None
1 to 2 times
3 to 5 times
GO TO D6
below
6 to 9 times
10 or more times

D7. In the past 12 months, have you used your
online medical record to…
Yes No

a. Make appointments with a health care
provider?...................................................
b. Request refill of medications? ..................
c.

D5. Why have you not accessed your medical
records online? Is it because…

Fill out forms or paperwork related to
your health care? ......................................

d. Request correction of inaccurate
information? ..............................................

D8. In the past 12 months, have you used your
online medical record to…

Yes No

a. You prefer to speak to your
health care provider directly? ...................

Yes No

a. Securely message health care provider
and staff (e.g., e-mail) .............................

b. You do not have a way to
access the website? ................................

b. Look up test results .................................
c.

You did not have a need to
use your online medical
record? .....................................................

GO TO D12
On the next
page

d. You were concerned about
the privacy or security of the
website that had your medical
records? ...................................................
d. Other (specify)
________________________

c.

d. Download your health information to
your computer or mobile device, such
as a cell phone or tablet ..........................
e. Add health information to share with
your health care provider, such as
health concerns, symptoms, and
side-effects ..............................................
f.

D6. Does your online medical record include
the following types of medical information?
Don’t
Yes No Know

Monitor your health ..................................

Help you make a decision about how to
treat an illness or condition......................

D9. Have you electronically sent your medical
information to…?
Yes

a. Laboratory test results .............................
b. Current list of medications .......................

a. Another health care provider? ..................

c.

b. A family member or another person
involved with your care? ...........................

List of health/medical problems ...............

d. Allergy list .................................................
e. Summaries of your office visit ..................
f.

c.

No

A service or app that can help manage
and store your health information? ...........

Clinical notes ............................................

g. Immunization or vaccination history .........

7

D10. How easy or difficult was it to understand
the health information in your online
medical record?
Very easy
Somewhat easy
Somewhat difficult
Very difficult

D11. In general, how useful are your online
medical records for monitoring your health?
Very useful
Somewhat useful
Not very useful
Not at all useful
Not applicable

D12. How confident are you that safeguards
(including the use of technology) are in
place to protect your medical records from
being seen by people who aren’t permitted
to see them?
Very confident
Somewhat confident
Not confident

D13. Have you ever kept information from your
health care provider because you were
concerned about the privacy or security of
your medical record?
Yes
No

D15. How many times did you access a family
member or close friend’s online medical
record in the last 12 months?
None
GO TO E1 below
1 to 2 times
3 to 5 times
6 to 9 times
10 or more times

D16. How did you access a family member or
close friend’s personal health information?
Yes No

a. Used family member’s login and
password ..................................................
b. Used a login and password assigned to
me to access their record .........................

E: Caregiving
E1. Are you currently caring for or making
health care decisions for someone with a
medical, behavioral, disability, or other
condition?
Mark X all that apply.
Yes, a child/children
Yes, a spouse/partner
Yes, a parent/parents
Yes, a close family member,
Yes, a friend or other non-relative
No
GO TO F1 on the next page

D14. If your medical information is sent
electronically – that is, by computer -- from
one health care provider to another, how
concerned are you that an unauthorized
person would see it?
Very concerned
Somewhat concerned
Not concerned

8

E2. Please check all conditions for which you
provided care for this person.
If you selected more than one person in
E1, please think about the individual for
whom you have provided the most care.
MarkX all that apply.
Cancer
Alzheimer’s, confusion, dementia,
forgetfulness
Orthopedic/Musculoskeletal Issues
(examples: back problems, broken bones,
arthritis, mobility problems, can’t get around,
feeble, unsteady, falling)
Mental Health/Behavioral/Substance Abuse
Issues
(examples: mental illness; emotional problems;
depression; anxiety; substance/drug/alcohol
abuse)
Chronic Conditions
(examples: high blood pressure/hypertension;
diabetes; heart disease; heart attack; lung
disease; emphysema; Chronic Obstructive
Pulmonary Disease (COPD); Parkinson’s)
Neurological/Developmental Issues
(examples: brain damage or injury;
developmental or intellectual disorder; mental
retardation; Down syndrome; stroke)
Acute Conditions
(examples: surgery, wounds/injuries)
Aging/Aging related health issues
Other (specify) _________________________
Not sure/ Don’t know

E3. Thinking of all of the kinds of help you
provide/provided for this person or
persons, about how many hours do you/did
you spend in an average week providing
care?
Less than 5 hours per week
5-14 hours per week
15-20 hours per week
21-34 hours per week
35 or more hours per week

F: Medical Research
F1. Doctors use DNA tests to analyze
someone’s DNA for health reasons. Have
you heard or read about this type of
genetic test?
Yes
No

GO TO G1 on the next page

F2. Which of the following uses of a genetic
test have you heard of?
Mark X all that apply.
Determining risk or likelihood of getting a
particular disease
Determining how a disease should be treated
after diagnosis
Determining which drug(s) may or may not work
for an individual
Determining the likelihood of passing an
inherited disease to your children

F3. Have you ever had any of the following
type(s) of genetic tests?
Mark X all that apply.
Paternity testing: To determine if a man is the
father of a child
Ancestry testing: To determine the
background or geographic/ethnic origin of an
individual’s ancestors
DNA fingerprinting: To distinguish between or
match individuals using hair, blood, or other
biological material
Cystic Fibrosis (CF) carrier testing: To
determine if a person is at risk of having a child
with cystic fibrosis
BRCA 1/2 testing: To determine if a person
has more than an average chance of
developing breast cancer or ovarian cancer
Lynch syndrome testing: To determine if a
person has more than an average chance of
developing colon cancer
None of the above
Not sure
Other-Specify

9

G: Your Overall Health
G1. In general, would you say your health is...

G6. Over the past 2 weeks, how often have you
been bothered by any of the following
problems?

Excellent,
Very good,
Good,
Fair, or
Poor?

G2. Overall, how confident are you about your
ability to take good care of your health?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

a. Little interest or pleasure in
doing things ..............................................
b. Feeling down, depressed, or
hopeless ...................................................
c.

Feeling nervous, anxious, or
on edge.....................................................

d. Not being able to stop or
control worrying ................................

G3. Has a doctor or other health professional
ever told you that you had any of the
following medical conditions:
Yes No

a. Diabetes or high blood sugar? .................

G7. Is there anyone you can count on to
provide you with emotional support when
you need it – such as talking over problems
or helping you make difficult decisions?
Yes
No

b. High blood pressure or hypertension? .....
c.

A heart condition such as heart attack,
angina, or congestive heart failure? .........

d. Chronic lung disease, asthma,
emphysema, or chronic bronchitis? .........
e. Arthritis or rheumatism? ...........................
f.

Depression or anxiety disorder? ..............

G4. About how tall are you without shoes?
Feet

and

Inches

G5. About how much do you weigh, in pounds,
without shoes?
Pounds

G8. Do you have friends or family members
that you talk to about your health?
Yes
No

G9. If you needed help with your daily chores,
is there someone who can help you?
Yes
No

G10. Are you deaf or do you have serious
difficulty hearing?
Yes
No

10

H: Health and Nutrition
H1. When available, how often do you use
menu information on calories in deciding
what to order?

H4. Which of the following health conditions do
you think can result from drinking too much
alcohol?
Don’t
Yes No Know

a. Cancer ......................................................

Always
Often
Sometimes
Rarely
Never

b. Heart Disease ...........................................
c.

Diabetes ...................................................

d. High cholesterol ........................................
e. Liver disease ............................................

H2. About how many cups of fruit (including
100% pure fruit juice) do you eat or drink
each day?
None
½ cup or less
½ cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

1 cup of fruit could be:
- 1 small apple
- 1 large banana
- 1 large orange
- 8 large strawberries
- 1 medium pear
- 2 large plums
- 32 seedless grapes
- 1 cup (8 oz.) fruit juice
- ½ cup dried fruit
- 1 inch-thick wedge of
watermelon

H3. About how many cups of vegetables
(including 100% pure vegetable juice) do
you eat or drink each day?
None
½ cup or less
½ cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

f.

Being overweight or obese .......................

H5. How much do you agree or disagree with
each of the following statements?

a. Alcohol increases your risk of
cancer .......................................................
b. Drinking alcohol in moderation
reduces your risk of heart
disease .....................................................

1 cup of vegetables could be:
- 3 broccoli spears
- 1 cup cooked leafy greens
- 2 cups lettuce or raw greens
- 12 baby carrots
- 1 medium potato
- 1 large sweet potato
- 1 large ear of corn
- 1 large raw tomato
- 2 large celery sticks
- 1 cup of cooked beans

11

I4.
I: Physical Activity, Exercise, and UV
Exposure
I1.

In a typical week, how many days do you
do any physical activity or exercise of at
least moderate intensity, such as brisk
walking, bicycling at a regular pace, and
swimming at a regular pace?
None
GO TO I4 in the next column
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

I2.

How many times in the past 12 months
have you used a tanning bed or booth?
0 times
1 to 2 times
3 to 10 times
11 to 24 times
25 or more times

I5.

Do you ever have your skin examined by a
health professional for signs of skin
cancer?
No
Yes, but not regularly
Yes, Regularly
I don’t know

I6.

Do you ever check your skin for signs of
skin cancer?
No
Yes, but not regularly
Yes, Regularly

On the days that you do any physical
activity or exercise of at least moderate
intensity, how long do you typically do
these activities?
Write a number in one box below.
Minutes

I: Tobacco Products

Hours

J1.
I3.

In a typical week, outside of your job or
work around the house, how many days do
you do leisure-time physical activities
specifically designed to strengthen your
muscles such as lifting weights or circuit
training (do not include cardio exercise
such as walking, biking, or swimming)?
None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

Have you smoked at least 100 cigarettes in
your entire life?
Yes
No

J2.

GO TO J5 on the next page

How often do you now smoke cigarettes?
Everyday
Some days
Not at all
GO TO J5 on the next page

J3.

At any time in the past year, have you
stopped smoking for one day or longer
because you were trying to quit?
Yes
No

12

J4.

Are you seriously considering quitting
smoking in the next six months?
Yes
No

J5.

Have you ever used an e-cigarette, even
one or two times?
Yes
No

J6.

GO TO J7 below

At any time in the past year, have you
talked with your doctor or other health
professional about having a test to check
for lung cancer?
Yes
No
Don’t know

J8.

In your opinion, do you think that some
smokeless tobacco products, such as
chewing tobacco, snus, and snuff are less
harmful to a person’s health than
cigarettes?
Yes
No
Don’t know

J9.

Much less harmful,
Less harmful,
Just as harmful,
More harmful,
Much more harmful, or
I’ve never heard of Hookah.

Do you now use an e-cigarette every day,
some days or not at all?
Everyday
Some days
Not at all

J7.

J10. A hookah pipe (or shisha) is a large water
pipe. People smoke tobacco using hookah
pipes in groups at cafes or bars. Compared
to smoking cigarettes, would you say that
smoking tobacco using a hookah is…

New types of cigarettes are now available
called electronic cigarettes (also known as
e-cigarettes or personal vaporizers). These
products deliver nicotine through a vapor.
Compared to smoking cigarettes, would
you say that electronic cigarettes are …
Much less harmful,
Less harmful,
Just as harmful,
More harmful,
Much more harmful, or
I’ve never heard of electronic cigarettes

K: Screening for Cancer
K1. Are you male or female?
Male
GO TO K6 on the next page
Female

K2. Has a doctor ever told you that you could
choose whether or not to have the Pap
test?
Yes
No

K3. How long ago did you have your most
recent Pap test to check for cervical
cancer?
A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a Pap test

K4. A mammogram is an x-ray of each breast
to look for cancer.
Has a doctor ever told you that you could
choose whether or not to have a
mammogram?
Yes
No

13

K5. When did you have your most recent
mammogram to check for breast cancer, if
ever?
A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a mammogram

L3.

Yes
No
Not sure

L4.

K6. The following questions are about
discussions doctors or other health care
professionals may have with their patients
about the PSA test that is used to look for
prostate cancer.

L5.

Yes
No

Yes
No

L6.

L1. Have you ever heard of HPV? HPV stands
for Human Papillomavirus. It is not HIV,
HSV, or herpes.

L2.

a. Cervical Cancer? ................................
b. Penile Cancer? ................................
c.

L7.

Do you think HPV can cause…
Yes

Anal Cancer? ...........................................

d. Oral Cancer? ............................................

In your opinion, how successful is the HPV
vaccine at preventing cervical cancer?
Not at all successful
A little successful
Pretty successful
Very successful
Don’t know

L: HPV Awareness

GO TO L5 in the best column

A vaccine to prevent HPV infection is
available and is called the HPV shot,
cervical cancer vaccine, GARDASIL®, or
Cervarix®.
Before today, have you ever heard of the
cervical cancer vaccine or HPV shot?

K7. Has a doctor ever discussed with you
whether or not you should have the PSA
test?
Yes
No

Do you think HPV requires medical
treatment or will it usually go away on its
own without treatment?
Requires medical treatment
Will usually go away on its own

Have you ever had a PSA test?

Yes
No

Do you think that HPV is a sexually
transmitted disease (STD)?

Including yourself, is anyone in your
immediate family between the ages of 9
and 27 years old?
Yes
No

Not
No sure

L8.

GO TO M1 on the next page

In the last 12 months, has a doctor or
health care professional ever talked with
you or an immediate family member about
the HPV shot or vaccine?
Yes
No
Don’t know

14

L9.

In the last 12 months, has a doctor or
health care professional recommended that
you or someone in your immediate family
get an HPV shot or vaccine?
Yes
No
Don’t know

M4. Did you ever receive any treatment for your
cancer?
Yes
No

GO TO M8 below

M5. Which of the following cancer treatments
have you ever received?

M: Your Cancer History
M1. Have you ever been diagnosed as having
cancer?
Yes
No

Yes No

a. Chemotherapy (IV or pills) ........................
b. Radiation ..................................................
c.

GO TO N1 on the next page

M2. What type of cancer did you have?
Mark X all that apply.
Bladder cancer
Bone cancer
Breast cancer
Cervical cancer (cancer of the cervix)
Colon cancer
Endometrial cancer (cancer of the uterus)
Head and neck cancer
Hodgkin's lymphoma
Leukemia/Blood cancer
Liver cancer
Lung cancer
Melanoma
Non-Hodgkin lymphoma
Oral cancer
Ovarian cancer
Pancreatic cancer
Pharyngeal (throat) cancer
Prostate cancer
Rectal cancer
Renal (kidney) cancer
Skin cancer, non-melanoma
Stomach cancer
Other-Specify

M3. At what age were you first told that you had
cancer?
Age

Surgery .....................................................

d. Other .........................................................

M6. About how long ago did you receive your
last cancer treatment?
GO TO M10
Still receiving treatment
on the next
page
Less than 1 year ago
1 year ago to less than 5 years ago
5 years ago to less than 10 years ago
10 or more years ago

M7. Did you ever receive a summary document
from your doctor or other health care
professional that listed all of the treatments
you received for your cancer?
Yes
No

M8. Were you ever denied health insurance
coverage because of your cancer?
Yes
No

M9. Looking back, since the time you were first
diagnosed with cancer, how much, if at all,
has cancer and its treatment hurt your
financial situation?
Not at all
A little
Some
A lot
15

M10. Clinical trials are research studies that
involve people. They are designed to test
the safety and effectiveness of new
treatments and to compare new treatments
with the standard care that people currently
get. Have you ever participated in a clinical
trial for treatment of your cancer?

N: Beliefs About Cancer
Think about cancer in general when
answering the questions in this section.
N1. How likely are you to get cancer in your
lifetime?
Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

Yes
No
Don’t know

M11. Has a doctor or other member of your
medical team discussed clinical trials as a
treatment option for your cancer?

N2. How much do you agree or disagree with
each of the following statements?

Yes
No

M12. At any time since you were first diagnosed
with cancer, did any doctor or other
healthcare provider ever discuss with you
the impact of cancer or its treatment on
your ability to work?
Discussed it with me in detail
Briefly discussed it with me
Did not discuss it at all
I don’t remember
I was not working at the time of my diagnosis.

a. It seems like everything
causes cancer ................................
b. There’s not much you can do
to lower your chances of
getting cancer ................................
c.

There are so many different
recommendations about
preventing cancer, it's hard
to know which ones to follow ....................

d. In adults, cancer is more
common than heart disease .....................
e. When I think about cancer, I
automatically think about
death.........................................................

N3. How much do you agree or disagree with
the statement: “I’d rather not know my
chance of getting cancer.”
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

N4. How worried are you about getting cancer?
Not at all
Slightly
Somewhat
Moderately
Extremely
16

N5. Have any of your family members ever had
cancer?

O5. What is your marital status?
Mark X only one.
Married
Living as married
Divorced
Widowed
Separated
Single, never been married

Yes
No
Not sure

O: You and Your Household
O1. What is your age?
Years old

O2. What is your current occupational status?
Mark X only one.
Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other-Specify

O3. Have you ever served on active duty in the
U.S. Armed Forces, military Reserves or
National Guard? Active duty does not
include training in the Reserves or National
Guard, but DOES include activation, for
example, for the Persian Gulf War.
Yes, now on active duty
Yes, on active duty in the last 12 months but
not now
Yes, on active duty in the past, but not in the
last 12 months
No, training for Reserves or
GO TO O5
National Guard only
in the next
column
No, never served in the military

O6. What is the highest grade or level of
schooling you completed?
Less than 8 years
8 through 11 years
12 years or completed high school
Post high school training other than college
(vocational or technical)
Some college
College graduate
Postgraduate

O7. Were you born in the United States?
Yes
No

GO TO O9 below

O8. In what year did you come to live in the
United States?
Year

O9. How well do you speak English?
Very well
Well
Not well
Not at all

O4. In the past 12 months, have you received
some or all of your health care from a VA
hospital or clinic?
Yes, all of my health care
Yes, some of my health care
No, no VA health care received

17

O10. Are you of Hispanic, Latino/a, or Spanish
origin? One or more categories may be
selected.
MarkX all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish
origin

O14. Starting with yourself, please mark the sex,
and write in the age and month of birth for
each adult 18 years of age or older living at
this address.
Sex

SELF

Male
Female

Adult 2

Male
Female

Adult 3

Male
Female

Adult 4

Male
Female

Adult 5

Male
Female

O11. Do you think of yourself as…
Heterosexual, or straight
Homosexual, or gay or lesbian
Bisexual
Something else – Specify

O12. What is your race? One or more categories
may be selected.

O13. Including yourself, how many people live in
your household?

Month Born
(01-12)

O15. How many children under the age of 18 live
in your household?
Number of children under 18

MarkX all that apply.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

Age

O16. Do you currently rent or own your home?
Own
Rent
Occupied without paying monetary rent

O17. Does anyone in your family have a working
cell phone?
Yes
No

O18. Is there at least one telephone inside your
home that is currently working and is not a
cell phone?
Yes
No

Number of people

18

O19. Thinking about members of your family
living in this household, what is your
combined annual income, meaning the
total pre-tax income from all sources
earned in the past year?

O21. At which of the following types of
addresses does your household currently
receive residential mail?
MarkX all that apply.
A street address with a house or building
number
An address with a rural route number
A U.S. post office box (P.O. Box)
A commercial mail box establishment (such as
Mailboxes R Us, and Mailboxes Etc.)

$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

O20. About how long did it take you to complete
the survey?
Write a number in one box below.
Minutes

Hours

Thank you!
Please return this questionnaire in the postage-paid envelope within 2 weeks.
If you have lost the envelope, mail the completed questionnaire to:
HINTS Study, TC 1046F
Westat
1600 Research Boulevard
Rockville, MD 20850

19