* 2. Have you ever been told by a doctor or other health professional that you have (fill in all that apply):

  Yes No Do not know
Arthritis
Heart problems
Diabetes (sugar)
High blood pressure
Asthma
Emphysema or bronchitis (breathing problems)
High blood cholesterol
Uncorrectable vision problems or blindness
Hearing loss
Cancer
Had a stroke
Chronic disease(s) of the nervous system (such as MS) or muscles
Problems of the stomach or intestines
Weight problem

* 3. In the past 12 months, have you had a (fill in all that apply):

  Yes No Do not know
General health exam
Blood pressure check
Cholesterol check
Flu shot
Blood stool test
Dental exam/ teeth cleaned
IF FEMALE: Pap test
IF FEMALE: Breast exam by a health care provider
IF FEMALE: Breast x-ray or mammogram

* 4. In the past 5 years, have you had a (fill in all that apply):

  Yes No Do not know
Hearing test
Eye exam
Diabetes check
Skin cancer screen
Pneumonia shot
IF AGE 40 or OLDER: rectal exam
IF AGE 50 or OLDER: a colonoscopy
IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA

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