Your ID (First two letters of your first name, first two letters of your last name, last two numbers of your birth year)

1. How old are you today ________ years.

2. Are you male or female?

MaleFemale

3. Are you of Hispanic or Latino, or Spanish origin?.

YesNo

4.What is your race? (Mark all that apply)

American Indian or Alaska nativeAsianBlack or African-AmericanNative Hawaiian or other Pacific IslanderWhite

5. Has a health care provider ever told you that you have any of the following chronic conditions? (Please mark all that apply)

Alzheimer's or related DementiaArthritis or Rheumatic DiseaseAsthma/Emphysema/Other Chronic Breathing or Lung ProblemCancer or Cancer SurvivorChronic PainHypertension (High Blood Pressure)Kidney DiseaseObesityOsteoporosis (Low Bone Density)Schizophrenia or Other Psychotic DisorderStrokeOther Chronic ConditionNone (No Chronic Conditions)

6. Did the past year, did you provide regular care or assistance to a friend or family member with a long term health problem or disability?

YesNo

7. Are you deaf or hard of hearing?

YesNo

8. Are you blind or have significant difficulty seeing even with glasses?
YesNo

9. Because of a physical, mental, or emotional condition, do you have serious difficulty walking or climbing stairs, dressing or bathing, or doing errands alone such as visiting the doctor's office or shopping?

YesNo

10. Do you live alone?

YesNo

11. What is the highest grade or year of school you completed?
Some elementary, middle or high schoolHigh School or GEDSome College or technical schoolCollege 4 years or more

12. In general, would you way that your health is:
ExcellentVery GoodGoodFairPoor

13. Did your doctor or healthcare provider suggest that you take this program?

YesNo