Personal Background

1. What is your gender?         Female         Male         Other

2. What is your age?         Under 21         21-30         31-40         41-50         51-60         Above 60+

3. What is your race/ethnicity?         Caucasian         Asian         African American         Hispanic         Native American         Middle Eastern         Other         Do not know

4. What is your highest level of education?         No formal education         Elementary school         Junior high school         High school         G.E.D         Home school         Associate degree         Bachelor's degree         Master's         Ph.D.

5. What is your occupation?         Part-Time         Full-Time         Student         Healthcare         Military         Agriculture         Professional         Managerial         Retail         Sales         Education         Service         Other

6. What area of the United States do you currently reside in? (As defined by the US Census)         Northeast         Midwest         South         West         Do not know         I live outside the United States

7. Do you currently have health insurance? If no skip next three questions         Yes         No

8. If "Yes" to the previous question, then what kind of insurance?         Managed Care         Fee for Service         Health Maintenance Organization (HMO)         Point of Service Plans (POS)         Preferred Provider Organization (PPO)         Medicare         Medicaid         Do not Know

9. What types of services does your insurance cover?         Physical exams         Care by specialists         Hospitalization and emergency care         Prescription drugs         Vision care         Dental services         Care and counseling for mental health         Services for drug and alcohol abuse         Obstetrical-gynecological care and family planning services         Ongoing care for chronic (long-term) diseases, conditions, or disabilities         Physical therapy and other rehabilitative care         Home health, nursing home, hospice care, long-term care         Chiropractic or alternative health care, such as acupuncture         Experimental treatments         Other

10. Are you satisfied with your medical coverage?         Yes         No         Do not know

11. If "No" to health insurance, has it ever hindered you from seeking medical attention?         Yes         No         Do not know

12. Which of the following health conditions have you had or currently suffer from?         Cancer, breast         Cancer, Colon         Cancer, lung         Cancer, Prostrate         Cancer, other         Heart disease         AID/HIV         Stroke         Mental Illness         Pneumonia/influenza         Asthma         Diabetes         Sexual transmitted disease         Do not know         Other

13. Have you smoked more than 20 cigarettes?         Yes         No         Do not know

14. Do you exercise 3 or more times a week?         Yes         No         Do not know

15. On average do you consume more than 10 drinks in a week?         Yes         No         Do not know

16. How would you rate your health status?         Excellent         Good         Fair         Poor         Extremely poor         Do not know

17. Do you believe health disparities have a direct relationship with health status?         Definitely         Somewhat         Possibly         Not at all         Do not know

18. Have you ever been mistreated by a medical professional?         Yes         No         Do not know

19. If yes to previous question, do you believe it was because of your race?         Yes         No         Do not know

20. The United States should have a universal healthcare plan.         Strongly Agree         Agree         Neutral         Disagree         Strong Disagree         Do not know

Health Disparities Survey
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