TXHC-Signs and Symptoms of Stroke & Heart Attack 2020

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* 1. Please check where you live:

Bloomington (Zip code: 77951)

Inez (Zip code: 77968)

McFadden (Zip code: 77973)

Nursery (Zip code: 77976

Placedo (Zip code: 77977

Telferner (Zip code: 77988)

Victoria (Zip code: 77901)

Victoria (Zip code: 77902)

Victoria (Zip code: 77904)

Victoria (Zip code: 77905)

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* 2. How many people are in your household?

1-2

3-4

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* 3. How many children (if any) are in:

*Enter a number in the field (use 0 if none)

Pre-K (0-4)

Elementary School (K-5th)

Middle School (6th-8th)

High School (9th-12th)

None

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* 4. What is your annual household income?

Less than $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

Over $60,000

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* 5. How often do you see your family doctor?

1x year physical and lab work

2x year physical and lab work

Only when needed for seasonal illnesses

None

Other (please specify)

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* 6. Do you or anyone in your household have heart disease?

Yes

Not sure

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* 7. Do you or anyone in your household have high blood pressure?

Yes

Not sure

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* 8. Do you or anyone in your household have high cholesterol?

Yes

Not sure

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* 9. Do you or anyone in your household have diabetes?

Yes

Not sure

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* 10. Which of the following are factors in causes of stroke and/or heart attack? (check all that apply)

Diabetes

High Cholesterol

Gout

High blood pressure

Arthritis

Heart disease

Back pain

Acid reflux

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* 11. Do you know the signs of a stroke?

Yes

Not sure

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* 12. Which of the following are signs of a stroke? (check all that apply)

Numbness or weakness on one side of the body

Confusion

Trouble speaking

Diarrhea

Lack of coordination

Leg cramps

Loss of balance

Trouble seeing in one or both eyes

All of the above

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* 13. Do you know what F.A.S.T (the key for stroke) stands for?

Yes (Please list answer below)

Don't know

Answer:

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* 14. Do you know the signs of a heart attack?

Yes

Don't know

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* 15. Which of the following are signs of a heart attack? (check all that apply)

Chest pain or discomfort

Shortness of breath

Diarrhea

Discomfort or pain in arm or shoulder

Leg cramps

Nausea

Lightheadedness

Cold sweat

All of the above

TXHC-Signs and Symptoms of Stroke & Heart Attack 2020

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* 1. Please check where you live:

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* 2. How many people are in your household?

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* 3. How many children (if any) are in:*Enter a number in the field (use 0 if none)

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* 4. What is your annual household income?

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* 5. How often do you see your family doctor?

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* 6. Do you or anyone in your household have heart disease?

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* 7. Do you or anyone in your household have high blood pressure?

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* 8. Do you or anyone in your household have high cholesterol?

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* 9. Do you or anyone in your household have diabetes?

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* 10. Which of the following are factors in causes of stroke and/or heart attack? (check all that apply)

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* 11. Do you know the signs of a stroke?

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* 12. Which of the following are signs of a stroke? (check all that apply)

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* 13. Do you know what F.A.S.T (the key for stroke) stands for?

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* 14. Do you know the signs of a heart attack?

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* 15. Which of the following are signs of a heart attack? (check all that apply)

* 3. How many children (if any) are in:

*Enter a number in the field (use 0 if none)