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Exit Survey
 
 
How old are you?
   
 
 
 
What is your gender?
 
Male
 
Female
 
Transgender
 
Other
 
 
 
 
What is your race? Please select all that apply.
 
Black/African American
 
American Indian or Alaska Native
 
White/Caucasian
 
Asian/Asian American
 
Native Hawaiian/Pacific Islander
 
Hispanic/Latino/Latina
 
Other
 
 
 
 
What is your current relationship status?
 
Single/divorced
 
Married/domestic partnership/living with a partner
 
Dating, not living together
 
Widowed/grieving the loss of a partner
 
Other
 
 
 
 
Where do you live?
 
City/urban area/downtown
 
Suburbs
 
Small town
 
Rural area/on a farm
 
Other
 
 
 
 
What part of the country do you live in?
 
Northeast, New England
 
South, Southeast
 
Southwest, West
 
Plains, Midwest
 
Non-continental U.S., U.S. territories
 
Other
 
 
 
 
Do you have health insurance? Select all that apply:
 
Yes, through my employer
 
Yes, through my partner's employer
 
Yes, through my parents
 
Yes, through an individual policy that I purchase
 
Yes, through Medicare
 
Yes, through Medicare plus a Medicare supplement
 
Yes, though Medicaid
 
No, I do not have health insurance
 
 
 
What is the highest level of education that you have completed?
 
Junior high
 
High school
 
Some college, 1 or 2 year degree or certificate
 
College degree (Bachelors)
 
Some graduate school
 
Graduate degree (ex: MA, MS, PhD, PsyD, MD, etc)
 
 
 
What was your total 2013 household income, before taxes?
   
 
 
 
What is your current weight in pounds?
   
 
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