Speak Your Mind! Reader Survey

(and Win Free Stuff)

As a parent, your children’s health is a priority. Real Health wants to know about their health issues and what parenting topics you would like to read about in the future. Real Health is giving away two Golden Towel Warming Racks (left, a $149 value) from Midnight Velvet, a catalog of distinctive clothing, accessories, beauty supplies and home furnishings. For more information about Midnight Velvet, visit www.midnightvelvet.com or call 800.383.5283. To enter, take the reader survey at www.realhealthmag.com/survey or fill out the following survey and mail to: Real Health c/o Smart + Strong, 500 Fifth Avenue, Suite 320, New York, NY 10110 or fax it to 212.675.8505. For the official contest rules, visit www.realhealthmag.com/survey/rules.
 
1. Name
 
2. Organization (if you represent one)
 
3. Street address:
 
4. City
 
5. State
 
6. ZIP code
 
7. E-mail
 
8. Phone
 
9. Are you a primary caretaker for children in your household? (If no, skip to question 19.)
Yes
No
 
10. If yes, how many children?
 
11. What are their ages? (Check all that apply.)
Newborn to 3 years old
4 to 8 years old
9 to 12 years old
13 to 17 years old
18 to 21 years old
21 years and older
 
12. Are you the child's or children's…?
Mother or father
Grandparent
Aunt or uncle
Other: 
 
13. Besides your children, for whom else are you a primary caretaker in your household?
Parents
Grandparents
Other: 
 
14. Do your children have health insurance?
Yes, through private health insurance
Yes, through medicaid or other public government health insurance
No
 
15. How often do your children go to the doctor, clinic or emergency room?
More than once a year
Annually
Every two years
It’s been a while
 
16. Have your children had all of their immunization shots?
Yes
No
Some, but not all
 
17. Do your children suffer from any of the following? (Check all that apply.)
Attention deficit/hyperactivity disorder
Allergies, food allergies and/or asthma
Anxiety or depression
Bed-wetting and soiling
Behavioral problems
Cancer
Diabetes
Ear, nose and throat problems
Headaches
High blood pressure
High cholesterol
HIV/AIDS
Learning disabilities
Sickle cell anemia
Sleep problems
Weight problems
Other: 
 
18. Which of the following do you use to maintain/improve your children’s health? (Check all that apply.)
Exercise/sports
Encourage them to eat better
Vitamins
None of the above
Other: 
 
19. What parenting/family-related topics would you like to see in future issues? (Check all that apply.)
Autism/learning disability issues
Building self-esteem
Childhood illnesses/health conditions
Dental health
Discipline/behavioral issues
Family fitness or exercise
First aid and safety
Food/diet/weight loss/nutrition
Gay families
Hearing and vision care
How to talk to children about sex, HIV/STDs, drugs, alcohol or cigarettes
How to talk to your children’s doctor
Parenting newborns and toddlers
Puberty
Single parenting
Other: 
 
20. What year were you born?
 
21. Gender
Female
Male
Transgender
Other: 
 
22. Ethnicity (Check all that apply.)
African American or black
American Indian or Alaskan Native
Arab or Middle Eastern
Asian
Caucasian or white
Hispanic or Latino
Native Hawaiian or Pacific Islander
Other: 
 
23. Household income
Less than $15,000
$15,000 – $34,999
$35,000 – $49,999
$50,000 – $74,999
$75,000 – $99,999
$100,000 or more
 
24. Employment status
Employed, full-time
Employed, part-time
Freelance/contractor
On disability
Retired
Student
Unemployed
Other: 
 
25. Marital status
Single, never married
Single, divorced or separated
Married
In a relationship, not living together
In a relationship, living together