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Exit Survey
 
 
What diagnoses have you received for your mental illness (select all that apply)?
 
Depression
 
Anxiety
 
Eating Disorder
 
Addiction

 
 
What diagnoses have you received for physical illness (select all that apply)?
 
Chron's Disease
 
Celiac Disease
 
Gluten or Lactose Intolerant
 
Gastroparesis or other gastrointestinal problem
 
Other
 

 
 
How do these diagnoses affect you and your life?
   
 
 
How long have you been dealing with these illnesses?
   
 
 
What age and gender are you? What is your first initial?
   
 
 
What kind of help (if any) are you seeking now?
 
Doctor (General) Appointments
 
Specialty Doctors
 
Therapist
 
Psychiatrist/ Medication
 
Other
 
 
 
What do you think caused your illnesses (if you know)?
   
 
 
 
Mention a time that you did something you regret due to your illness.
   
 
 
What is something that you wish other people would know about chronic illnesses?
   
 
 
 
How would you define yourself without your illness? How does your illness define you?
   
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