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* 1. Which services would you like to have more available on Lana’i?

  High Priority - 3 Medium Priority - 2 Low Priority - 1 Don’t Know - 0
Dental Care
Medical Care for Elderly
Mental Health/Behavioral Health
Children’s Health Care
Pregnancy Care
Traditional Healing
Support Groups
Health Education
Gynecology

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* 2. What other health services would you like to have more available on Lana'i?

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* 3. Please pick the top three most important health issues on Lana'i:

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* 4. If you feel there are important health issues on Lana'i not listed above, please list below.

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* 5. Background Information - Male or Female?

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* 6. Background Information - What is your age?

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* 7. Background Information - What is the highest level of education you have completed? Please choose ONE.

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* 8. Which of the following categories best describes your gross household income during the last year?

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* 9. How many people live in your home, including yourself?

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* 10. Which ethnicity do you identify most with?

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* 11. Health Problems you currently have: (Please list)

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* 12. Would you like to be contacted? If yes, please provide information for desired contact method:

Name: _______________________________________________________________

Email: _______________________________________________________________

Telephone: __________________________________________________________

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