This free survey is powered by
Create a Survey
Surveys
2013
August
L
Living Well Assessment
Living Well Assessment
0%
Exit Survey
Demographics
How old are you?
How would you describe your race/ethnicity?
American Indian/Alaska native
Asian
Black, non-Hispanic
Hispanic
What language do you feel most comfortable speaking?
English
I am
Male
Female
Transgender M to F
Transgender F to M
Don't know
Refused
Missing
Education, Income & Employment
What is the highest level of education you completed?
8th grade or less
Some college
Some high school
College degree
High School / GED
Graduate school or Vocational Training
What best describes your work situation in the last 6 months?
-- Select --
Employed full time
Employed part-time
A homemaker
A full-time student
Retired
Disabled for work
Unemployed
Don't know
Refused
Missing
b. If you are not working, why not?
i. Student; Looking for a job; Retired; For health reasons; and I’m on disability; For health reasons; and I’m not on disability; Other (specify:_________________)
Other
Medical History / Perceived Health
Loading...
close
Loading...
Close
qprun1.questionpro.net