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-ar • _■ yF_ _, .{ 11111 -�.. : .. . . .v <br /> • HEALTHCARE NEEDS SURVEY <br /> 117 s ND -TED , 'LE. E CH <br /> 1 . Are you currently: <br /> 1) Married <br /> 2) Single <br /> 3) Divorced <br /> 4) Widowed <br /> 2. Sex: <br /> 1) Male <br /> 2) Fema l e <br /> 3. Including yourself, how many members are in your household? <br /> (Please write the number) <br /> 4. How old are the members of your household, and how many are there <br /> in each age group? (Please include yourself, write the number of <br /> persons in the appropriate space and indicate their sex.) <br /> ' EXAMPLE: l-son aged 2 and a daugTiter aged 3 would be recorded as: <br /> Age Number Sex <br /> 1 - 4 2. 111 IF1 <br /> Age Humber Sex <br /> less than 1 M F <br /> 1 - 4 M F <br /> 5 - 14 M F <br /> 15 - 24 M F <br /> 25 - 44 M F, <br /> 45 - 64 M F <br /> 65 + M F <br /> 5. Is your income? <br /> 1) Below $4,000 <br /> 2) $4,001 to $10,000 <br /> 3) $10,001 to $15,000 <br /> 4) $15,001 to $20,000 <br /> 5) Above $20,000 <br /> 6. How long have you lived in this community? <br /> 1) Less than 1 year <br /> 2) 1 - 5 years <br /> 3) 5 - 10 years <br /> 4) Longer than 10 years _ <br />