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* 1. What is your age range?

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* 2. What is your gender?

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* 3. In which region of state do you live?

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* 4. In what type of an area do you live?

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* 5. What is your highest education level attained?

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* 6. Did you learn something new as a result of watching the "Heart Disease" program?

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* 7. Have you, or will you, change any of your behaviors or habits as a result of watching the "Heart Disease" program?

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* 8. Did you find the program on "Heart Disease" helpful?

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* 9. How many of the monthly HealthWise programs have you seen?

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* 10. Overall, have you found the programs helpful?

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* 11. What is your primary source for health information?
(check all boxes that apply.)

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* 12. First and Last Names

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* 13. Mailing Address(Street Address or P.O. Box):

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* 14. City:

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* 15. State:

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* 16. ZIP Code:

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