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* 1. In general, would you say that your health is:

* 2. About how long has it been since you last visited a doctor or other health care professional for a routine check-up?

* 3. During the past 12 months was there a time when you thought you needed medical care but did not get it or delayed getting it?

* 4. Why did you not get or delay getting the medical care you thought you needed? PLEASE CHECK ALL THAT APPLY.

* 5. How would you rate your overall level of stress?

* 6. During the past 30 days for about how many days have you felt sad, blue, or depressed?

* 7. During the past 12 months was there a time when you wanted to talk with or seek help from a health professional about emotional problems such as stress, depression, excess worrying, troubling thoughts or emotional problems, but did not or delayed talking with someone?

* 8. Why did you not get or delay getting the care you thought you needed? PLEASE CHECK ALL THAT APPLY.

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