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��•_ .. : ma V -„ :y. "%AV- <br /> UNLESS OTHERWISE INDICATED PLEASE CHECK THE APPROPRIATE SPACE S <br /> 7. Please indicate your education level by circling the appropriate number <br /> of years in school : <br /> 5 6 7 8 9 10 11 12 13 14 15 16 16+ <br /> CURRENT HEALTH STATUS <br /> 8. How would you describe your health? <br /> 1) Very good health <br /> 2) Good health <br /> 3) Fair health <br /> 4) Poor health <br /> 5) Very poor health <br /> 9. Do you have a good appetite? <br /> 1) Yes ❑ 2) No D <br /> 10. Do you sleep well at night most of the time? <br /> 1) Yes ❑ 2) No [, <br /> 11. Do you currently have a personal physician, one doctor that you see when <br /> you need healthcare services? <br /> 1) Yes ❑ 2) No fl <br /> 12. Have you or a member of your family sought health care in the past three <br /> (3) months? <br /> 1) Yes ❑ 2) No 0 <br /> } 13. Where do you get routine health care now? <br /> 1) Doctor's office <br /> 2) Emergency clinic <br /> 3) Hospital emergency room <br /> 4) Place of employment <br /> 5) Other (Please specify) <br /> 14. How did you first find out about the place where you now receive health <br /> care? <br /> 1) Personal physician <br /> 2) Yellow Pages <br /> 3) Recommended by family/friend/ <br /> neighbor <br /> 4) Community agency <br /> 5) Other (Please specify) <br /> 15. Are you satisfied with the health care services you now receive? <br /> 1) Yes 0 2) No ❑ <br /> 3) Have not needed care (] <br />