YES!!! I Will Answer Questions About the TakeCHARGE Campaign: 5 Steps to Safer Healthcare!

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The TakeCHARGE Campaign needs you to help share the message of how people can plan to be patients and complete the 5 Steps to improve our healthcare outcomes. Please share with us how you helped others throughout the campaign, have you followed the steps and what you have done to promote the campaign.

Other ways to share are through The TakeCHARGE Campaign Facebook Page, Instagram, Linkedin and Twitter or e-mail direct to TheTakeCHARGECampaign@gmail.com

I learned about The TakeCHARGE Campaign through

E-mail

Social Media

Web Search

Press Release

Other:

Name of social media site

Name of person from where you received the TakeCHARGE information

Has the information you learned caused you to look at how well you are prepared as a patient?

Yes

Comment (next question)

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How has the TakeCHARGE information raised your awareness?

How often to you see a doctor or other healthcare professional?

Once a year for a well visit

A few times a year

I go when I don't feel well

I rarely or almost never go (less than once a year)

Other:

Please check which of the 5 Steps you have made you rethink your planning to be a well prepared patient.

#1 Understand and complete your advance directives

#2 Keep a record of your medical history and medications

#3 Prepare for your medical visit / make a list of question (and symptoms)

#4 Prevent infections/ ask caregivers to wash their hands

#5 Use and advocate / be an advocate for others

Your Name (optional)

Age

16-19 years old

20-25 years old

26-30 years old

31-40 years old

41-50 years old

51-60 years old

61-70 years old

over 71 years old

Other:

Clear selection

City / State / Zip Code or Country

Will you share information with others?

Yes

Not sure

Other:

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Tell us your story! Please share additional information that may make this helpful to improving The TakeCHARGE Campaign

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