Needs Assessment | Praise in Pink

Email address *

Message *

Tell Us About It *

Any history of Breast Cancer? _____________________________________
Do you perform self-examination? ____________________
Have you ever had a mammogram? _________________
If you have not had breast exam, why not? _______________________
Do you have a primary care provider? _____________________________
Are you interested in obtaining more information regarding breast cancer? ______________________
What kind of information do you have an interest in? ______
Is there someone you have in mind that may need assistance with this the services of Praise in Pink? ___________________________________________________
Have you had breast cancer? _________________________
Anyone close to you had/have breast cancer? ______________________________
Have you had anyone assist you with the step-by-step processes? _____________________
Are you still under therapy? What kind of therapy?______________________________
How much longer do you have for your therapy? __________________________________
Do you feel anxious of scared when you go for your appointments? __________________________
Have you spoken to a therapist since your diagnosis? ____________________________________
Who is your main support person? ___________________________________
How often do you visit your primary care physician? ______ ______________
How do you get there? _____________________
What kind of services do you think are needed in your area? (list as many as you need to)