14. Please compl ete sentence
14. Please compl ete sentence
14. Please compl ete sentence
below.
Are you:
below.
Are you:
Yes
below.
Are you:
Yes
a) Eating right (Daily5+servings-fruits/veg/wheat)??
Yes
a) Eating right (Daily5+servings-fruits/veg/wheat)??
b) Using tobacco products weekly?
?
a) Eating right (Daily5+servings-fruits/veg/wheat)?
?
b) Using tobacco products weekly?
?
c) Exercising 2-3 times weekly?
?
b) Using tobacco products weekly?
?
c) Exercising 2-3 times weekly?
?
d) Consuming alcohol (more than 1 drink daily)? ?
c) Exercising 2-3 times weekly?
?
d) Consuming alcohol (more than 1 drink daily)? ?
?
e) Receiving an annual flu shot?
d) Consuming alcohol shot?
?
?
e) Receiving an annual flu(more than 1 drink daily)?
?
e) III: A LITTLE MORE
Part Receiving an annual flu shot? ABOUT YOU
Part III: A LITTLE MORE ABOUT YOU
15. Wha is your age ?
Part III:t A LITTLE MORE ABOUT YOU
15. Wha t is your age ?
? Under is
15. Wha t 18 your age ?? 18 - 44
? Under 18
? 18 - 44
? Under 18
? 18 - 44
16. Your gender?
16. Your gender?
? Male
?
16. Your gender?Female
? Male
? Female
? Male
? Female
17. How w oul d you identi fy yoursel f?
17. How w oul d you identi fy yoursel f?
? a) Caucasian d you identi
17. How w oul/ White American fy yoursel f?
? a) Caucasian / White American
b) African American / Black American
?? a) Caucasian / White American
? b) African American / Black American
c) Latino / Hispanic American
?? b) African American / Black American
? c) Latino / Hispanic American
Other (please specify)
? c) Latino / Hispanic American
No
No
?
N
?o
?
?
?
?
?
?
?
?
?
?
?
?
N/A
?
?
?
?
?
N/A
N/A
?
?
?
?
?
?
?
?
?
(Note: questions in this section are required for reporting purposes.)
? 45 - 64
? 45 - 64
? 45 - 64
Other (please specify)
? 65 - 74
? 65 - 74
? 65 - 74
? Over 75
? Over 75
? Over 75
? d) American Indian / Native Alaskan
? d) American Indian / Native Alaskan
? e) Asian American // Pacific Alaskan
? d) American Indian Native Islander
? e) Asian American / Pacific Islander
? e) Multicultural / MultiracialIslander
? f) Asian American / Pacific
? f) Multicultural / Multiracial
? f) Multicultural / Multiracial
Other (please specify)
18. How woul d you descri be your house hold?
18. How woul d you descri be your house hold?
18.? Singlewoul d you descri be your house hold?
How
? Single
Married
?? Single
? Married
Married with
?? Married children at home
? Married with children at home
? Married with children at home
19. Regardi ng your heal t h insurance coverage,
19. Regardi ng your heal t h insurance coverage,
prim ary plan? (Choose one )
19. Regardi ng your heal tone )
prim ary plan? (Choose h insurance coverage,
Private Insurance you purchased
?prim ary plan? (Choose one )
? Private Insurance you purchased
Medicare
?? Private Insurance you purchased
? Medicare
Medicaid
?? Medicare
? Medicaid
Other (please specify)
? Medicaid
? Married with children no longer at home
? Married with children no longer at home
? Divorcedwith children no longer at home
? Married
? Divorced
? Other ___________________________________
? Divorced
? Other ___________________________________
? Other ___________________________________
what type of hea lt h coverage
what type of hea lt h coverage
what type of hea lt h coverage
is your
is your
is your
? Covered by Employer (employer pays total cost)
? Covered by Employer (employer pays total cost)
share cost)
? Covered by Employer (you & employertotal cost)
? Covered by Employer (employer pays share cost)
? Covered by Employer (you & employer
? Covered by Employer (you & employer sha &R6?7B??????6?fW&vR?V???7W&VB??????6?fW&vR?V???7W&VB??????6?fW&vR?V???7W&VB????F?W"??V6R7V6?g?????F?W"??V6R7V6?g????#?v?B?2??W"???RRF?v?B??6?FR?B6?V?G???#?v?B?2??W"???RRF?v?B??6?FR?B6?V?G???#?v?B??W"???RRT6?V?G???R??6?FR6?FR?B6?V?G???#?v?B?6?2??W"???F?v?BF?v?B???B6?V?G??b&W6?FV?6S???????????????? ??B?????R??B?????R??B?????R?6?V?G???6?V?G????6?V?G????V6R"RGW&?6???WFVB7W'fR?v?F?V?6??6VB'W6??W72&W??R?fV??R???V6R"RGW&?6???WFVB7W'fR?v?F?V?6??6VB'W6??W72&W??R?fV??R???V6R"RGW&???W"6???WFVB7W'fR?v?F?V?6??6VB'W6??W72&W??R?fV??R??