Speak Your Mind! Winter 2006 Reader Survey

(and Win Free Stuff)

Juggling mulitple health issues is a reality for many Real Health readers and their family members. We want to know if you face any wellness challenges and what you do to manage them. Real Health is giving away ten copies of Not in My Family, a collection of personal essays by black Americans, including Mo'Nique and Real Health's Marvelyn Brown, whose lives have been affected by HIV/AIDS. To enter, take the reader survey below. 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. Do you suffer from any of the following? (Check all that apply.)
Asthma/allergies
Anxiety/depression
Diabetes
High blood pressure
High cholesterol
None of the above (Skip to question 18.)
 
10. Which of the following do you use to manage your health? (Check all that apply.)
Acupunture/holistic medicine
Exercise/sports
Healthier eating
Medications
Montitoring blood pressure/sugar
Psychotherapy
Vitamins/herbs
None of the above
Other: 
 
11. If you are on presciption medication for diabetes, which ones are you taking? (Check all that apply.)
Actos
Amaryl
Avandia
Byetta
Glucophage
Other: 
 
12. If you are on presciption medication for high blood pressure, which ones are you taking? (Check all that apply.)
Coreg
Diovan
Lasix
Lisinopril
Norvasc
Other: 
 
13. If you are on presciption medication for high cholesterol, which ones are you taking? (Check all that apply.)
Crestor
Lipitor
Tricor
Zetia
Zocor
Other: 
 
14. If you are on presciption medication for asthma/allergies, which ones are you taking? (Check all that apply.)
Advair
Dexamethasone
Flonase
Nasacort
Pulmicort
Other: 
 
15. If you are on presciption medication for depression/anxiety, which ones are you taking? (Check all that apply.)
Lexapro
Paxil
Prozac
Wellbutrin
Zoloft
Other: 
 
16. Do you take your medications as prescribed?
Yes (Skip to question 18.)
No
Sometimes
 
17. If you answered "no" or "sometimes," what are your reasons? (Check all that apply.)
I can't afford medications.
I don't have insurance.
I don't need to.
I keep forgetting.
I am depressed.
I sleep through dosing time.
I am too busy.
I ams away from home/traveling.
I am too sick.
I have side effects.
I don't trust doctors/medical community.
Other: 
 
18. Does your child suffer from any of the following? (Check all that apply.)
Asthma/allergies
Anxiety/depression
Diabetes
High blood pressure
High cholestrol
 
19. Does your partner/spouse suffer from any of the following? (Check all that apply.)
Asthma/allergies
Anxiety/depression
Diabetes
High blood pressure
High cholesterol
 
20. Does your parent suffer from any of the following? (Check all that apply.)
Asthma/allergies
Anxiety/depression
Diabetes
High blood pressure
High cholesterol
 
21. What did you enjoy in the Winter 2006 issue of Real Health? (Check all that apply.)
Health News
Gastric Bypass
Fitness
HIV Report Card
Relationships
Superfood Recipes
Heroes
Clearing Clutter
S. Epatha Merkerson
 
22. What year were you born?
 
23. Gender
Female
Male
Transgender
Other: 
 
24. 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: 
 
25. Employment status
Employed, full-time
Employed, part-time
Freelance/contractor
On disability
Retired
Student
Unemployed
Other: 
 
26. What is your household income?
 
27. Marital status
Single, never married
Single, divorced or separated
Married
In a relationship, not living together
In a relationship, living together