Partners Health Needs Assessment

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* 1. What is your gender?

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* 2. What is your age?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. Which SOFCC location do you most regularly attend?

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* 5. What is your zip code?

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* 6. In general, how would you rate your overall health?

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* 7. Over the past 7 days, how many servings of fruits and vegetables did you eat daily?

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* 8. About how many days per week do you exercise for 30 minutes or more?  (This may include: brisk walking, cycling, jogging, other recreational sports NOT to include housework or physical activity that may be a part of your job.)

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* 9. Where do you most commonly buy your food? (Please rank ONLY those that apply).  Ranking guide: 1 = most common, 8 = least common

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* 10. On average, how long does it take you to get from your house to where you most commonly shop for food?

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* 11. What type of health insurance do you currently have?

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* 12. At what type of healthcare facility do you usually receive your medical care? (Check all that apply.)

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* 13. Do you or an immediate family member have any of the following health-related problems that require regular doctor visits or daily medication?  (check all that apply.)

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* 14. Which of the following health topics are of interest to you? (Check all that apply)

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* 15. Do you have any other health-related comments, questions, or concerns?

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