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) ________________________________________________________________

________________________________________________________________