Exit this survey
1
. How did you hear about this program?
How did you hear about this program?
Physician
Church
Advertisement
Friend
Other
Florida Tobacco QuitLine
2
. What is your birth year
What is your birth year
3
. What is your zip code
What is your zip code
4
. What is your gender?
What is your gender?
Male
Female
5
. Are you Hispanic, Latino or of Spanish origin?
Are you Hispanic, Latino or of Spanish origin?
Yes
No
Unknown
6
. Please select one or more of the following that best describes your race:
Please select one or more of the following that best describes your race:
American Indian or Alaska Native
Asian or Asian-American
Black or African American
Hawaiian Native or Pacific Islander
White/Caucasian
Other
7
. Please indicate which ongoing health conditions you have:
Please indicate which ongoing health conditions you have:
Arthritis/rheumatic disease
Cancer
Depression
Epilepsy
Heart Disease
High Cholesterol
Hypertension/High Blood Pressure
Lung Disease (asthma, emphysema, bronchitis)
Obesity
Stroke
Other
I do not know if I have an ongoing health condition
I do not have an ongoing health condition
8
. Have you participated in a previous Walk With Ease session?
Have you participated in a previous Walk With Ease session?
Yes
No
*
9
. First and Last Name
First and Last Name
10
. Worksite
Worksite
11
. Courier Route (if known)
Courier Route (if known)
A
B
C
D
E
*
12
. SAP number
SAP number
*
13
. Email address
Email address
14
. Telephone Number
Telephone Number
*
15
. Mailing Address
Mailing Address
16
. City and State
City and State
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