2020 Pampered Ladies Conference

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* 1. Name

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* 2. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. What is your race or ethnicity?

African American

Hispanic or Latino

Asian or Pacific Islander

Caucasian

Self-describe below:

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* 4. What is your age?

18 to 34

35 to 50

51 to 64

65 or older

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* 5. Have you ever used tobacco products including ENDS?

Yes

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* 6. Are you familiar with bewellarkansas.org or 833-283-WELL?

Yes

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* 7. Are you familiar with ACT 811?

Yes

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* 8. Have you or anyone in your immediate family been diagnosed with breast, lung, prostate, or cervical cancer?

Yes

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* 9. Are you a caregiver of a cancer survivor?

Yes

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* 10. Do you allow alcohol use in your home?

Yes

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* 11. Is alcohol accessible to children under the age of 21?

Yes

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* 12. Do you have Diabetes?

Yes

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* 13. Do you have a primary physician?

Yes

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* 14. Have you had a physical exam in the last year?

Yes

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* 15. If so, when?

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* 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

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* 17. Have you been provided with the following screenings over the past year?

Blood Pressure

Glucose

Cholesterol

Dental

Vision

HIV

Mammograms

Prostate

Sickle Cell

2020 Pampered Ladies Conference

Question Title

* 1. Name

Question Title

* 2. Address

Question Title

* 3. What is your race or ethnicity?

Question Title

* 4. What is your age?

Question Title

* 5. Have you ever used tobacco products including ENDS?

Question Title

* 6. Are you familiar with bewellarkansas.org or 833-283-WELL?

Question Title

* 7. Are you familiar with ACT 811?

Question Title

* 8. Have you or anyone in your immediate family been diagnosed with breast, lung, prostate, or cervical cancer?

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* 9. Are you a caregiver of a cancer survivor?

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* 10. Do you allow alcohol use in your home?

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* 11. Is alcohol accessible to children under the age of 21?

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* 12. Do you have Diabetes?

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* 13. Do you have a primary physician?

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* 14. Have you had a physical exam in the last year?

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* 15. If so, when?

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* 16. Have you been provided with the following screenings over the past 6 months?

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* 17. Have you been provided with the following screenings over the past year?

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* 18. If you had one question you would like to ask a doctor, what would it be?