| carefully fill out this survey, choosing the ones that most apply to you. If you come across a question that seems complicated or that makes you feel incomfortable, you may choose the "i don't want to answer" option or skip the question and write "skipped" as your answer choice. This survey is only to signify the leading health risk in the community. Any person participating in this survey is anonymous and the information provided are remained confidential. After completeing the survey, carefully hand it back to the person that distributed it to you.Thank you for participating on this survey.
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| what is the number one leading health risk in your community? |
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| Including yourself, how many people at the age of 40-60 do you know have these diseases? |
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| Have you ever been hospitalized for having: |
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| How Many people do you know have cancer? |
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| How many people between the ages of 40-60 do you know have diabetes? |
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| How many people between the ages of 40-60 do you know are suffering from High blood pressure? |
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| do you have any family member between the ages of 40-60 with any of these diseases? If so, specify. |
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| How many people in your community between ages 40-60 are suffering from HIV/AIDS? |
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| Do you know any body ages 40-60 facing an abesity problem? |
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| How many men and women in your community have heart disease? |
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| Are there any other health risk in your community of concern among people age 40-60? If so, specify. |
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| Do you view these risks as a concern in your community? |
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| Are you satisfied with health care for people with such diseases in you community? |
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| Are you familiar with anybody age 40-60 suffering from any of these heath related issues? |
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| How many family members between the ages of 40-60 have any of these health problems? |
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| Is your family at risk with any of these health issues? |
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