* 1. What is your age range?

* 2. Has a doctor ever told you that you had any of the following?

* 3. Was there a time in the last 12 months when you needed to see a doctor, but could not because of cost? 

* 4. About how long has it been since you last visited a doctor for a routine check-up?

* 5. What are the reason(s) you have not seen the doctor?

* 6. Do you smoke cigarettes? 

* 7. About how long has it been since you had your blood pressure taken by a health professional?

* 8. In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?

* 9. Have a doctor or other health professional ever talked with you about your diet or eating habits?

* 10. Has a doctor or other health professional ever talked with you about physical activity?

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