Health Lifestyles

Exit Survey

What is your gender?

Male

Female

What is your age?

18-24

25-44

45-64

65 +

What is your race?

Caucasian

African American

Latin American

Asian American or Pacific Islander

Native American or Alaska Native

Biracial or multiracial

What is the highest level of education you have completed?

Grammar School

High School diploma/ GED

Associate's degree

Some College/ Currently in college

Bachelor's degree

Master's degree or higher

What is your annual income?

Less than $25,000

$25,000-$50,000

$50,000- $75,000

$75,000 or more

Do you percieve yourself as healthy?

Yes

No

Do you believe in the power of prayer to a higher being?

Yes

No

How often do you visit the doctor?

Every 1-3 months

Every 4-6 months

Annually

Never

Out of the following, which type(s)of care do you receive? Please select all that apply.

Primary Care Physician

Optometry (eye/vision health)

Dentist (oral health)

Gynecologist (women's health)

Psychologist or Therapist (mental/emotional health)

None

Do you take any prescribed medication?

Yes

No