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HEAL Survey

HEAL HEALTH SURVEY

1. Age *This question is required.
2. Sex *This question is required.
3.
Do you have a regular physician?
*This question is required.
4. When was the last time you visited a doctor?
5. Do you have any of the following?
6. Have you been treated for any of these conditions?
7. Do you have Health Insurance? *This question is required.
8. Do you smoke? *This question is required.
9. Have you been seen in an Emergency Room in the past two years? *This question is required.
10. If you have ever participated in a Clinical Research Study, was it: *This question is required.
11.
Would you be willing to take part in a Clinical Research Study if you know it would improve the health of our community?                     
*This question is required.
12. If you would NOT be willing to participate in a Clinical Research Study, why not?
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