Breast & Cervical Cancer Pre-Screen

Short form. Takes 2–3 minutes. Answers are confidential.

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What happens after I submit?

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Step 1: Review (Today)

A health worker will review your answers. If you qualify, you'll get a voucher code via SMS.

Step 2: Visit the Facility (Within 7 days)

Go to the designated health facility
Show your voucher code
Get your free screening

Step 3: Results & Follow-up

The facility will give you results and next steps if needed. Everything is confidential.

Need help? Ask a Community Health Promoter (CHP) at the screening site.

Unique ID (from chit)

…

If you don't have a chit, leave it blank. You can still continue.

Section A – Your information Date of pre-screening Defaults to today. Change only if you’re filling this later. Where are you today? (Community/Church)

Ngecha Catholic Church

Riara Ridge Catholic Church

Other

Please specify church/community

Select your location from the options above. Full Name (as on ID or church list) Please write all three names if possible.

Age (years)

Phone (Safaricom/Airtel) We use this to send an SMS with next steps.

Alternative phone (optional) Village / Sub-location Consent to continue?

Yes, I agree No

If you select "No", we will stop and not record any details.

Section B – Breast symptoms Lump in breast or underarm?

Yes No

Nipple discharge (especially blood)?

Yes No

Change in breast shape/skin?

Yes No

Breast pain not related to periods?

Yes No

Section C – Cervical symptoms Unusual vaginal bleeding (after sex, between periods, or after menopause)?

Yes No

Foul-smelling vaginal discharge?

Yes No

Pain during sex?

Yes No

Persistent pelvic or lower back pain?

Yes No

Section D – Screening & access history Ever been screened for breast cancer?

Yes No

Ever been screened for cervical cancer?

Yes No

Ever missed screening due to cost, distance, or fear?

Yes No

Ever treated for any of the above symptoms?

Yes No

Section E – Support & household In the last 12 months, were you unable to get care because of cost?

Yes No

Currently unemployed or without stable income?

Yes No

Are you the sole provider for your dependents?

Yes No

Do you have 5+ dependents in a low-income household?

Yes No

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