| Question item | Selection item |
| Q1 Age | ,20 s ,30 s , 40 s , 50 s , 60 s , 70 s+ |
| Birth experience | , YES , NO |
| Breastfeeding experience | , YES , NO |
| Q2 Have you ever undergone breast cancer screening? | , YES |
| What content of examination did you receive? | , Mammography only |
| , Ultrasonograhy only | |
| , Both | |
| , NO | |
| What is the interval of examinations? | , Regularly (every year & every other year) |
| , Sometimes | |
| , Previous once | |
| Q3 Do you know “dense breasts”? | , I know the meaning the term |
| , I had only heard the term | |
| , I do not know the term | |
| If you know the meaning, where? | , Consultation |
| , Media (TV·Magazine) | |
| , Acquaintance | |
| , Other ( ) | |
| If you know the meaning, would you wish to be notified? | , I would want to know |
| , It did not matter | |
| , I would not want to know. | |
| Do you know that ultrasound can also breast cancer screening? | , YES |
| , NO | |
| Q4 Do you conduct breast self-examination? | , Monthly |
|
| , Sometimes |
|
| , NO |
| If you answer NO, why? | , Bothersome |
|
| , Forget |
|
| , I do not know how |
|
| , I’m scared to find |
|
| , Unnecessary |
| Q5 Do you have presence of breast cancer sufferers | , YES |
| among close blood relatives | , Mother |
|
| , Sister |
|
| , Children |
|
| , Grandmother/aunt |
|
| , NO |