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* 1. Who provides your health promotion activity?

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* 2. Health Promotion Program attended:

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* 3. What is your age?

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* 4. What is your gender?

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* 5. What is your race?

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* 6. Has a health care provider ever told you that you have any of the following chronic conditions? Please mark all the apply.

  Yes No
Alzheimer's or related Dimentia
Arthritis/ Rheumatic Disease
Breathing/ Lung Disease (Asthma, Emphysema, etc.)
Cancer or Cancer Survivor
Chronic Pain
Depression or Anxiety Disorders
Diabetes
Heart Disease
High Cholesterol
Hypertension (High Blood Pressure)
Multiple Sclerosis
Osteoporosis (Low Bone Density)
Stroke
Other Chronic Condition
None ( If No Chronic Condition -  Check No )

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* 7. I found this Health Promotion Program useful.

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* 8. As a result of this program, I feel I have more skills.

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* 9. As a result of this program, my daily behaviors have improved or changed.

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* 10. Have you applied the skills you learned in your daily activities?

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* 11. As a result of this program, I feel more comfortable increasing my daily activity.

0 of 11 answered
 

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