1. How old are you?
   30 years old or less     31 to 50 years old    51 to 70 years old     71 years old or more
2. What is your ancestry?
   African-American    Asian    Caucasian    Hispanic    Native American    Other
3. Has your father, brother, uncle or grandfather (blood relatives only) ever been diagnosed with prostate cancer?
   Yes    No
4. With respect to your weight, do you consider yourself to be:
   Very thin    Thin    About normal    Somewhat overweight    Obese
5. How often do you eat fast food such as hamburgers and french fries, pizza, fried chicken, take-out Mexican food, take-out Chinese food or movie theater popcorn?
   Less than once a week    Two to three times a week    Four to five times a week    Once a day    Two to three times a day or more
6. How often do you eat other high-fat foods, such as potato chips, any other fried foods, ice cream, or other high-fat sweets?
   Less than once a week    Two to three times a week    Four to five times a week    Once a day    Two to three times a day or more
7. How often do you eat fruits or vegetables?
   Less than once a week    Two to three times a week    Four to five times a week    Once a day    Two to three times a day or more
8. Do you smoke?
   Yes    No
9. Do you receive yearly screening for prostate cancer by your physician?
   Yes    No

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