UACC General Health Survey
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Name *
Telephone *
Email *
Neighborhood *
City *
Demographics
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Age *
Sex *
Race *
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Ethnicity *
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Family Income *
Survey Questions
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Thinking of your family, what are the leading causes of illness?
Thinking of your family, what are the leading causes of death?
Do you have health insurance?
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If you said yes to the previous question, what kind of health insurance do you have?
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Do you get an annual medical checkup?
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Of these services, which are easily available to you?
Where do you usually go for medical services?
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Where do you go for mental health services?
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How would you rate your overall health?
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Do others in your household (those with whom you live) have better or worse health than you?
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If you have problems getting health care for you or your family, what are they?
If you selected more than one for the previous question, what was the main reason?
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