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Health Assessment Survey (Pilot)
This is a test instrument for a thesis. Responses are being collected to insure the questions are well-structured and the information collected is the information needed.
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- Please select your age from the list below:
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- Please select your gender from the list below
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- Please select your race / ethnicity from the list below. (Select all that apply)
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- Please rate your general health condition using the scale below:
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- How many days per week do you exercise?
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- How many days per week do you eat fast foods?
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- Please select the response that most describes the influence that religion or spiritual belief has on your health care practices.
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- Have you or anyone in your family ever suffered from any of the following conditions? Please select all that apply.
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- Have you ever been diagnosed with High Blood Pressure?
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- Do you currently take medication for High Blood Pressure?
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- If you answered "Yes" to Question #10, do you take your medication as prescribed by your physician?
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- If you answered "No" to Question #11, please select the response that most closely describes the reason you do not take your medications as presribed. (Select all that apply)
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- From the list below, please select the medications you currently take for High Blood Pressure. (Select all that apply)
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- How often do you visit a health care provider (doctor's office, hospital, or medical clinic)
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- Please select the response that most closely describes your primary health care provider
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- Please rate your agreement or disagreement with the following statements
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- What factors contribute to High Blood Pressure? Please select all that apply.
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- Please list three (3) conditions that can occur if High Blood Pressure is uncontrolled or left untreated.
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- What recommendations do you have to improve this survey or the way information is gathered?
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