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* 1. What is your gender?

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* 2. What is your age?

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* 3. What is your race? Mark one or more.

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* 4. Have you had a conversation with a loved one about your own end of life wishes?

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* 5. Have you had a conversation with a physician about your own end of life wishes?

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* 6. Do you view any of the following as barriers in discussing end of life wishes with a loved one? (check all that apply)

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* 7. Do you view any of the following as barriers in discussing end of life wishes with a physician? (check all that apply)

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* 8. On a scale of 0 to 10, with 0 being not at all comfortable and 10 being extremely comfortable, indicate your comfort in discussing end of life issues.

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* 9. What is your opinion about media coverage of end of life issues?

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* 10. What do think would enhance comfort in having end of life discussions?

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