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What is your name?

How old are you?

How many people do you know that have been affected by breast cancer?

Have you ever had a mammogram?    Yes    No

If not, why not?   

After visiting my website, will you utilize any of the prevention an early detection techniques mentioned?    Yes    No

If so, which techniques will you use?

        Monthly BSE
        Clinical breast examination
        Exercise regularly
        Eat more fruits and vegetables
        Remind others about breast cancer

Would you like to recommend anyone to visit this site?    Yes    No

If so, please list their email addresses.