NJN Public Television - Su Salud Primero/Your Health First

NJN Public Television - Su Salud Primero/Your Health First

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1. Health Survey

We want to hear from you. Tell us what your health concerns are by completing our short survey.

1. Do you have health care insurance? What type? If not, why not?

Do you have health care insurance? What type? If not, why not?

2. Have you been covered by NJ Charity Care?

Have you been covered by NJ Charity Care? Yes

No

3. If not insured, are there health clinics accessible to you?

If not insured, are there health clinics accessible to you? Yes

No

4. What are your eating habits? Do you exercise regularly?

What are your eating habits? Do you exercise regularly?

5. What medical conditions do you have?

What medical conditions do you have?

6. How often do you visit a physician? Do you visit a physician only when ill or needing emergency care?

How often do you visit a physician? Do you visit a physician only when ill or needing emergency care?

7. Does your physicians’ office have bilingual or bicultural staff?

Does your physicians’ office have bilingual or bicultural staff? Yes

No

8. Do you have prescription coverage? If not, how do you obtain your prescriptions?

Do you have prescription coverage? If not, how do you obtain your prescriptions?

9. Do you take vitamins regularly? What preventive strategies do you undertake to maintain your health?

Do you take vitamins regularly? What preventive strategies do you undertake to maintain your health?

*

10. Contact Information

Contact Information * Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
* Email Address:
Phone Number:

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