Step 1: Do You Know Your Health Risk Factors?

General Information
About You
1. What is your age?
2. What is your gender?
Select Male Female
3. Are you of Hispanic or Latino origin?
Select Yes No
4. What is your race? (Please check all that apply).
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other
5. What was the highest grade you completed in school?
Select 8th grade or less Some high school but I did not graduate High school graduate or GED Some college or 2-year degree 4 year college graduate Graduate school or more
6. How do you describe your employment?
Select Employed for wages Self-employed Out of work for more than 1 year Out of work for less than 1 year A homemaker A student Retired Unable to work
7. How would you rate your overall health?
Select Excellent Very good Good Fair Poor
8. Have you been told you have any of the following diseases or conditions? (Please check all that apply)
Arthritis Asthma Cancer Diabetes Heart disease Chronic Obstructive Pulmonary Disease (COPD) Overweight / Obese Osteoporosis Stroke None of the above
9. Do you use tobacco products (cigarettes, cigars, pipe, snuff, chew, or snus)?
Select Yes No
10. In the past 30 days, have you had a drink (beer, wine or liquor)?
Select Yes No
11. Do you have a primary healthcare provider?
Select Yes No
12. How do you pay for medical costs? (Check all that apply)
Indian Health Service MaineCare Medicare Military, CHAMPUS, or the VA Private health insurance Private health insurance with a high deductible Self-pay Other I don't know
13. Are you a Maine resident?
Select Yes No
14. What is your zip code?
15. From whom did you hear about KeepMEWell? (Please check all that apply)
My employer My local Healthy Maine Partnership My friend or family member My healthcare provider Maine Tobacco HelpLine GetBetterMaine Other I don't know
16. How did you hear about KeepMEWell? (Please check all that apply)
Brochure/card Mailing Newspaper Newsletter Poster Email Radio Website Other I don't know
17. Where are you taking this assessment?
Select Adult Education site Community site Employment and Training Center Healthcare site Library My home Someone else's home School Work site Other
18. How many times have you completed KeepMEWell in the past?
Select Never - this is my first time One time Two times More than two times I don't know

Step 1 of 4