Pre-Natal Demographics

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* 1. Which category below includes your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 2. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 3. Which of the following categories best describes your employment status?

Employed, working 40 or more hours per week

Employed, working 1-39 hours per week

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 4. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

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* 5. Where do you like to shop and socialize?

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* 6. How many pre-natal massages have you had?

Zero

1 to 3

3 to 6

7 to 9

More than 10

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* 7. Who do you go to for pre-natal care?

OBGYN

Midwife

Family Practitioner

Other (please specify)

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* 8. What are your goals for receiving massage?

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* 9. What are your philosophical beliefs about wellness?

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* 10. Thank you for taking time to fill out my survey, Please complete the information below to be entered in a free pre-natal massage raffle.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number