Community Survey | QuestionPro

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Age:
Gender (Male/Female):
Race (African-American/Black, White, Hispanic, Asian, other):
Religious Affiliation (Baptist, Catholic, non-denominational, Muslim, other) :

1. How satisfied are you with your appearance?

2. How important is exercise to you?

3. How often do you engage in exercise?

Never

Once a week

2-3 times

4 or more times

4. How many hours of TV, video, computer activity do you participate in daily?

0-1 hr

2-3 hours

4-5 hours

over 6 hours

5. How important is your health?

6. Do you have any health issues that you are aware of?

No

Yes, please indicate__________________

7. What health related topics are you interested in learning more about?

8. Are you sexually active?

No

Yes

9. How do you define safe sex?