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General Survey Form 3

This is a how's your health survey form.

General Survey Form 3
General Survey Form 3
How's Your Health Survey Form
What is your age or the age of the person for whom you are
completing the health check-up
New-born in intensive care (by parent for child)
2-4 (by parent for child)
50-64
5-8 (by parent for child)
65-69
9-13
70-79
14-17
80 or older
18-49
Are you or this person now in a hospital
Yes
No
Are you a female or a male
Male
Female
Have you completed this quiz within the past six months
Yes, I have completed in the past 6 months and would like to do it again
No
Yes, I have completed and would only like to review some of the reading materials again or
use the Problem Solving Method
After completing the survey, you will have the option to:
download your own Portable Health Record
General Survey Form 3
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