Appendix II                                              Back to Contents

Sample Questionnaire:

(based on Breast Health Access for Women with
Disabilities intake)

1. Please Answer The Following Questions Regarding Your Mobility Needs:

____No assistance
____Motorized Wheelchair
____Manual Wheelchair

Walk with:

____Cane
____Walker
____Furniture Support
____Other ______________________________________________________

2. Do You Need Assistance For:

____Rolling
____Balance (____Sit/____Stand)
____Bending/____Reaching
____Transfers
____Walking

3. What Other Assistance Might You Use/Need In Exam Settings?

_______________________________________________________________
_______________________________________________________________

4. Do You Have Trouble Using Your Hands For:

____Dressing
____Hand to mouth
____Grasp/____Release

5. Barriers To Breast Self-Exam:

____Lack of arm or hand control or coordination
____Tremors
____Impaired sensation in fingers
____Cannot reach
____Other (please specify) ________________________________________________________________
________________________________________________________________