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TXHC-Signs and Symptoms of Stroke & Heart Attack 2020
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)
2.
How many people are in your household?
1-2
3-4
5+
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
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
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)
6.
Do you or anyone in your household have heart disease?
Yes
No
Not sure
7.
Do you or anyone in your household have high blood pressure?
Yes
No
Not sure
8.
Do you or anyone in your household have high cholesterol?
Yes
No
Not sure
9.
Do you or anyone in your household have diabetes?
Yes
No
Not sure
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
11.
Do you know the signs of a stroke?
Yes
No
Not sure
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
13.
Do you know what F.A.S.T (the key for stroke) stands for?
Yes (Please list answer below)
No
Don't know
Answer:
14.
Do you know the signs of a heart attack?
Yes
No
Don't know
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
