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* 1. Name (First and Last) Optional

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* 2. What is your age

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* 3. What is your gender?

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* 4. What District do you live in? 

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* 5. In general, how would you rate your overall health?

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* 6. Do you have high blood pressure

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* 7. Are you diabetic?

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* 8. Are you pre-diabetic?

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* 9. Do you use commercial tobacco products (Check all that apply)

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* 10. About how many alcoholic drinks do you have each week?

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* 11. In a typical week, how many days do you exercise?

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* 12. Do you have access/membership to a gym? 

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* 13. In the past 30 days, how many times did you eat out at restaurants or fast food?

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* 14. Which activities would you be interested in? (Check all that apply)

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* 15. Please identify the three most important health issues in your community.

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* 16. Please identify the three most important unhealthy behaviors in your community.

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* 17. What other services would you like to see offered from your Kiowa Tribe Health Program? 

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* 18. How would you rate your Kiowa Tribe Health Program?

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