[6.] Racial/ethnic
identification
|
[7.] Education
|
[8.] Employment
Status
|
[9.] Your Yearly Income
|
[10.] Do you have health insurance?
|
|
[11.]If you have health Insurance what
kind (s)?
(check all that apply)
|
[12.] Do you have dental insurance?
|
[13.] How do you rate your health?
|
[14.] During the last month, how many
days have you been too sick to work or carry out your usual activities?
|
[15.] When was your last physical
check up?
|
[16.] Where do you go for routine health care?
|
[17.] Can you see a doctor when you need to?
Yes
No |
[18.] If you can't see a doctor, then why not (choose
only one please)?
|
[19.] Do you regularly go outside your county for
health services?
Yes
No |
[20.] If you regularly go outside your
county for health services, what services?
|
[21.] If you regularly go outside your county for
health services, why?
|
[22.] Where do you get most of your health-related
information?
Is it from: (please choose one)
|
[23.] Select any of the following that
you have had done in the last year:
|
[24.] Who do you think is most responsible
for keeping you healthy? (Please choose only one)
|
[25.] I wear a seat belt
|
[26.] I wear a helmet when riding a bicycle or motorcycle
|
[27.] I drive the speed limit
|
[28.] I eat at least five servings of fruit and
vegetables a day
|
[29.] I exercise at least 3 times a week
|
[30.] I maintain near to my desired weight
|
[31.] I use some type of tobacco
|
[32.] I drink more than 2 alcoholic drinks or beers
a day
|
[33.] I use illegal drugs
|
[34.] I see a dentist 1 or 2 times a year
|
[35.] I perform self-exams for cancer (breast or
testicle self-exam)
|
[36.] I get a physical exam every year or two years
as my doctor recommends
|
[37.] I get enough sleep each night
|
[38.] I feel stressed out
|
[39.] I feel happy about my life
|
[40.] I enjoy my job/responsibilities
|
[41.] I wash my hands with soap and water after
using the restroom
|
[42.] I wash my hands before preparing a meal or
handling food
|
[43.] I wash my hands before eating a meal
|
[44.] I wash my hands often during the day
|
[45.] I use sunscreen or protective clothing when
in the sun for an hour or more
|
[46.] I often feel lonely
|
[47.] I get a flu shot every year
|
[48.] I practice safe sex or I am in a long-term
monogamous relationship
|
[49.] I take vitamin pills or vitamin supplements
|
[50.] I gamble every week
|
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