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A Matter of Balance Pre-Survey

Welcome to our A Matter of Balance pre-survey. Thank you in advance for your time and input. All information requested in this form is used to support this community program. Asterisks mark questions or fields where answers are required. Otherwise, you may leave some questions blank if you are not comfortable answering.

1. Class code: *This question is required. This question requires a valid number format.

2. What is today's date? This question requires a valid date format of MM/DD/YYYY.

calendar

3. First name: *This question is required.

4. Last name: *This question is required.

5. Street Address: *This question is required.

6. City: *This question is required.

7. State: *This question is required.

8. Zip code: *This question is required.

9. County: *This question is required.

10. Email address: This question requires a valid email address.

11. Phone Number: *This question is required. This question requires a valid number format.

12. Verify your email address This question requires a valid email address.

13. Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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14. How old are you today? This question requires a valid number format.

15. What is your gender?

16. Are you of Hispanic, Latino or Spanish origin?

17. What is your race? Check all that apply.

18. What is your primary language?

Please enter an 'other' value for this selection.

19. What is the highest grade or level of school have you completed?

20. What is your marital status?

Married	Single	Separated	Divorced	Widowed
Married	Single	Separated	Divorced	Widowed

21. What is your insurance coverage?

Medicare
Medicaid
Private Insurance
Veterans Benefits
None
Other Please enter an 'other' value for this selection. * This question is required.

Do you have a Medicare Advantage Plan?

Who is your Medicare Advantage Plan Provider?

22. Do you live alone?

How many people are in your household, including yourself? This question requires a valid number format.

23. During the past year, did you provide regular care or assistance to a friend or family member who has a long-term disability?

24. Emergency Contact Information:

First Name

Last Name

Email Address

Phone Number This question requires a valid number format.

Relationship

25. Please indicate your monthly income. If you are married, please indicate the income that best represents your combined monthly income. This question requires a valid number format.

26. I am a veteran

27. I have a family member on active military duty.

28. Would you like to be contacted about future health care education classes and events?

Preferred method of contact:

29. Did your doctor, nurse, physical therapist, or other health care provider suggest that you take this program?

30. Do you have a primary care doctor or health care provider?

Please provide your health care provider information

Name

Phone Number This question requires a valid number format.