Health & Wellness Survey
Thank you for taking the time to complete this brief health survey. Your feedback is important to us and will help us improve the services we provide. As a token of our appreciation, upon completing the survey, you will be entered into a drawing to win a Turkey dinner for eight. The drawing will take place on November 20th. The winner has 48 hours to respond upon notification. We truly value your input and wish you the best all the best!
Age
What is your zip code?
What is your gender?
Male
Female
Transgender
Prefer Not To Say
Non Binary
Other
Do you smoke or vape?
Yes
No
How often do you exercise?
1 - 3 a week
3 - 5 a week
Everyday
Never
How often do you eat fresh fruits & vegetables?
1 - 3 a week
3 - 5 a week
Everyday
Never
Do you have a doctor that you see for medical reasons?
Yes
No
Have you used an emergency room in the last year?
Yes
No
Do you have reliable transportation?
Yes
No
Participate in our Thanksgiving Giveaway!
Please share your contact information to be notified should you win the Thanksgiving dinner for eight.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Submit Survey
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