Health and Wellness Resource Survey
Advocates for Community Wellness
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Name  *
Phone *
Email
Age
Gender *
What type of insurance do you have?
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Zip code *
 1. If you are 45 years or older, have you had a colorectal cancer screening? *
If you are 50 years or older with a history of smoking, have you had a lung cancer screening? Select one answer.
If you are a female 40 years or older, have you had your annual  mammogram?
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2. Do you have a primary doctor?
3.Have you had your annual wellness exam in the past 12 months.        
4. Do you need help with obtaining any of the following resources or health services.?        
5. Do you have a history of..... 
6. Are you interested in receiving emails with health information and events to learn how to be healthier?
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7. Are there young women in your household ages 14-19 years old who may be in need of health resources?
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