AetnaWomens Health   Breast Health
Women's Health Breast Health Program's Web Site Survey
 
The information obtained from this survey will be used to help Aetna enhance the clinical breast cancer programs we offer to our members, as well as, assist in the development of new programs. Any information provided will be kept completely confidential. Thank you for taking the time to complete the survey.
 
1.  How long have you been an Aetna member?
2.  What is your member ID number?
3.  To help us provide health-care information specific to you, tell us your age
4.  Tell us your gender
Female
Male
5.  To help us meet the health-care needs of specific populations, can you tell us your race/ethnicity?
African-American/Black
Caucasian (White)
Hispanic/Latino
Native American/American Indian
Multi-Racial
6.  Do you prefer getting health education information by e-mail (please provide)?
7.  If you are 40 or older when did you have your last mammogram?
6 months ago
1 year ago
2 or more years ago
8.  Have you been treated for breast cancer?
Yes
No
9.  If yes,
Within the last year
Within the last 3 years
More than 5 years ago
10.  How old were you when you were first diagnosed with breast cancer?
11.  Have you been recently diagnosed with breast cancer?
Yes
No
12.  If yes, have you made your decision on plan for treatment?
Lumpectomy
Mastectomy
Adjunct Therapy (chemotherapy, radiation therapy, hormone therapy)
13.  If you smoke, for how long?
Less than 3 years
More than 5 years
14.  What is your height?
15.  What is your weight?
16.  Would you like an Aetna case manager to call you to offer information of national organizations that can help?
Yes
No
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