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Do you have access to a primary care physician or a doctor?
   
 
 
 
Do you have readily access to medical information or support groups?
   
 
 
 
Are you willing to seek medical assistance?
 
Yes
 
No
 
 
 
How often in a year do you visit a doctor?
   
 
 
 
Do you have accessible transportation to medical help?
 
Yes
 
No
 
 
 
Are there known family history of cardiovascular disease (CVD)?
 
Yes
 
No
 
 
 
In a month, how many days do you exercise for at least 30 minutes?
   
Would you consider yourself living an "active" lifestyle?
   
 
 
 
Do you smoke? If yes, how often?
   
 
 
 
Do you drink alcohol? If yes, how often?
   
 
 
 
Do you eat fast food? If yes, how often?