1. What is your sex? |
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Female |
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Male |
2. What is your age? ____________________ |
3. What is your monthly income? |
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a. ≥$ 4,910.21 |
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b. $ 2,455.11 to $ 4,910.20 |
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c. $ 982.05 to $ 2,455.10 |
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d. $ 491.03 to $ 982.04 |
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e. $ 0 to $ 491.02 |
4. What is your educational level? |
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a. Incomplete elementary school |
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b. Complete elementary school |
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c. Incomplete high school |
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d. Complete high school |
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e. Further education |
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f. Graduate |
5. What is your marital status? |
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a. Single |
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b. Married |
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c. Divorced |
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d. Consensual marriage |
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e. Widow/er |
6. What is your race? |
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a. White |
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b. Brown (Pardo) |
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c. Mulatto |
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d. Asian |
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e. Black |
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f. Other: __________________ |
7. Are you a healthcare professional? |
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a. Yes |
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b. No |
7A. If yes, in which healthcare field? |
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a. Medicine |
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b. Physiotherapy |
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c. Occupational Therapy |
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d. Physical Education |
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e. Pharmacy |
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f. Audiology and Speech therapy |
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g. Nutrition |
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h. Dentistry |
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i. Psychology |
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j. Chiropractic care |
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k. Other: __________________ |
8. Have you ever been diagnosed with any type of cancer? |
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a. Yes |
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b. No |
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8A. If yes, which type? ____________________ |
9. Any close relatives (consider only grandfathers/grandmothers, father/mother, sons/daughters, and brothers/sisters) have ever been diagnosed with any type of cancer? |
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a.Yes |
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b. No |
9A. If yes, which type of cancer? ____________________ |
10. What is the most common type of cancer among men? |
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a. Mouth cancer |
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b. Esophageal cancer |
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c. Gastric cancer |
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d. Liver cancer |
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e. Intestinal cancer |
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f. Breast cancer |
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g. Pancreas cancer |
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h. Skin cancer* |
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i. Penile cancer |
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j. Prostate cancer |
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k. Lung cancer |
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l. Kidney cancer |
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m. I do not know the answer |
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n. Other: __________________ |
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*Correct answer: skin cancer (h) |
11. What is the most common type of cancer among women? |
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a. Mouth cancer |
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b. Esophageal cancer |
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c. Gastric cancer |
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d. Liver cancer |
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e. Intestinal cancer |
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f. Breast cancer |
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g. Pancreas cancer |
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h. Skin cancer* |
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i. Penile cancer |
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j. Prostate cancer |
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k. Lung cancer |
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l. Kidney cancer |
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m. I do not know the answer |
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n. Other: __________________ |
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*Correct answer: skin cancer (h) |
12. Have you ever searched or received prostate cancer information? |
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a. Yes |
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b. No |
12A. If yes, where did you search or receive prostate cancer information? (you can choose more than one option) |
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a. School/university |
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b. Workplace |
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c. Church/religious cult |
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d. Newspaper/magazine |
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e. Internet/social media |
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f. Physician/other healthcare professional |
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g. Friends |
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h. Family |
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i. Other: __________________ |
13. Prostate cancer affects which genders? |
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a. Both genders |
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b. Male* |
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c. Female |
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d. I do not know the answer |
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*Correct answer: male (b) |
14. Which of the factors below are prostate cancer risk factors? (you can choose more than one option) |
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a. Family history of cancer* |
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b. Stress |
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c. Alcohol use |
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d. Lack of hygiene |
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e. Age* |
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f. Masturbation |
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g. Socioeconomical range |
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h. Obesity* |
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i. Pollution |
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j. Race/ethnicity* |
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k. Frequent sexual relation |
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l. Smoking |
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m. I do not know the answer |
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n. Other: __________________ |
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*Correct aswers: family history of cancer (a); age (e); obesity (h); race/ethnicity (j) |
15. Which of the factors below can prevent or decrease prostate cancer risk? (you can choose more than one option) |
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a. Eat red meat every week |
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b. Eat fruits and vegetables* |
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c. Physical exercise* |
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d. Routine blood tests* |
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e. Body weight control* |
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f. Do not keep the mobile phone in your pocket |
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g. Avoid many sexual relations |
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h. Do not masturbate |
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i. Use sun protector |
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j. I do not know the answer |
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k. Other: __________________ |
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*Correct answers: eat fruits and vegetables (b); physical exercise (c); undergo routine blood tests (d); body weight control (e) |
16. When should you seek medical care related to prostate cancer? |
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a. Only when presenting correlated symptoms (example: blood in urine) |
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b. Asymptomatic, between 30 to 40 years |
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c. Asymptomatic, between 41 to 50 years* |
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d. Asymptomatic, between 51 to 60 years |
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e. Asymptomatic, between 61 to 70 years |
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f. I do not know the answer |
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g. Other: __________________ |
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*Correct answer: asymptomatic, between 41 to 50 years (c) |
17. How often should you return to the physician for prostate cancer monitoring? |
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a. Every 2 years |
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b. Every 3 years |
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c. Every 4 years |
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d. Every 5 years |
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e. Annually (every year)* |
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f. No need to return if the exams are normal |
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g. I do not know the answer |
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h. Other: __________________ |
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*Correct answer: annually (e) |
18. What exams are needed in the initial prostate cancer investigation? (you can choose more than one option) |
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a. Digital rectal exam* |
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b. Nuclear magnetic resonance |
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c. Blood test/PSA* |
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d. Urine test |
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e. Bone test |
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f. Prostate ultrasonography |
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g. I do not know the answer |
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*Correct answers: digital rectal exam (a); blood test/PSA (c) |
19. QUESTION ONLY FOR MEN – When was the last time you saw a physician for prostate-related exams? |
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a. This year |
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b. 1 year ago |
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c. 2 years ago |
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d. 3 years ago |
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e. 4 years ago |
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f. 5 years ago |
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g. More than 5 years ago |
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h. Never |
20. QUESTION ONLY FOR MEN – Have you ever done blood exam for prostate cancer? (PSA dosage exam – prostatic specific antigen)? |
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a. Yes |
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b. No |
21. QUESTION ONLY FOR MEN – Have you ever done the digital rectal exam? |
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a. Yes |
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b. No |
21A. QUESTION ONLY FOR MEN – If you did not do the digital rectal exam, why you did not do it? (you can choose more than one option) |
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a. It interferes in anal or rectal anatomy/physiology |
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b. It interferes sexual potency |
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c. It interferes sexuality (sexual interest) |
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d. It is painful |
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e. Physician did not request it |
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f. Fear |
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g. I am not old enough |
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h. It does not need to be done |
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i. I have no worries. I would do it, it is no problem |