Healthcare Survey

Healthcare Profile A

 
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1. Have you or your family member(s) seen a medical doctor in the last 12 months for a health concern?
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2. Have you or your family member(s) seen an alternative medicine (or healing art) practitioner in the last 12 months for a health concern?

NOTE: An alternative medicine practitioner may practice Acupuncture, Ayurveda, Chinese medicine, Chiropractic, Homeopathic, or Naturopathic medicine.
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3. Do you have a chronic illness?

Note: A chronic illness may be one of the following: Acquired Hypothyroidism,
 Alzheimer's Disease 
or Senile Dimentia, Asthma, Atrial Fibrillation,
 Autism, Benign Prostatic Hyperplasia, Cancer (Colorectal, Endometrial, Breast, Lung, Prostate),
 Cataract,
 Chronic Back Pain, Chronic Debilitating Allergies (food, pollen, mold, etc.), Chronic Kidney Disease,
 Chronic Obstructive Pulmonary Disease, 
Depression,
 Diabetes,
 Glaucoma,
 Heart Disease or Failure, 
Hip / Pelvic Fracture
 Hyperlipidemia, 
Hypertension, 
Ischemic Heart Disease,
 Obesity, Osteoporosis,
 Rheumatoid Arthritis / Osteoarthritis,
 or Stroke / Transient Ischemic Attack.
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4. What chronic illness(es) do you and your family member(s) have? Select ALL that apply.

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