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2020 Pampered Ladies Conference
1.
Name
2.
Address
Address
Address 2
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Country
Email Address
Phone Number
3.
What is your race or ethnicity?
African American
Hispanic or Latino
Asian or Pacific Islander
Caucasian
Self-describe below:
4.
What is your age?
18 to 34
35 to 50
51 to 64
65 or older
5.
Have you ever used tobacco products including ENDS?
Yes
No
6.
Are you familiar with bewellarkansas.org or 833-283-WELL?
Yes
No
7.
Are you familiar with ACT 811?
Yes
No
8.
Have you or anyone in your immediate family been diagnosed with breast, lung, prostate, or cervical cancer?
Yes
No
9.
Are you a caregiver of a cancer survivor?
Yes
No
10.
Do you allow alcohol use in your home?
Yes
No
11.
Is alcohol accessible to children under the age of 21?
Yes
No
12.
Do you have Diabetes?
Yes
No
13.
Do you have a primary physician?
Yes
No
14.
Have you had a physical exam in the last year?
Yes
No
15.
If so, when?
16.
Have you been provided with the following screenings over the past 6 months?
Blood Pressure
Glucose
Cholesterol
Dental
Vision
HIV
Mammograms
Prostate
Sickle Cell
17.
Have you been provided with the following screenings over the past year?
Blood Pressure
Glucose
Cholesterol
Dental
Vision
HIV
Mammograms
Prostate
Sickle Cell
18.
If you had one question you would like to ask a doctor, what would it be?
Current Progress,
0 of 18 answered