Respondent Profile

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* 1. Please indicate your age range:

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* 2. Please indicate your gender:

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* 3. Please indicate the range of your household’s annual income:

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* 4. What is your mother tongue (first language learned and still understood)?

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* 5. Which language is most often spoken in your home?

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* 6. Where were you born?

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* 7. Please enter your postal code:

Physical State of Health

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* 8. Generally, you would say that your health is:

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* 9. Has a health professional diagnosed you as having a chronic health condition? (By this, we mean a health problem or condition which has lasted for 6 months or more.)

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* 10. If yes, please check the condition(s) that apply to you:

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* 11. Please indicate any other condition or disease diagnosed by a health professional:

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* 12. Do you need the help of another person to carry out daily activities?

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* 13. If yes, please indicate the extent to which you require help on a daily basis:

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* 14. Do you currently have a family doctor?

Mental State of Health

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* 15. You would describe yourself as being usually:
 
(Check ONE answer only.)

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* 16. How would describe you usual ability to think and solve day-to-day problems:

(Check ONE answer only.)

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* 17. If you could improve some aspect of your physical and/or mental health in any way, what would it be?

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* 18. What is the single most important change you made in recent years to improve your physical and/or mental health?

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* 19. What is the most important change you could make to improve your physical and/or mental health?

Health Information Sources

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* 20. Where do you usually go for health information and tips?  

 (Check all applicable answers.)

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* 21. Before visiting this web site, had you ever heard of Réseau santé albertain?

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