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Health Survey
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1) What country are you from?
<SELECT NAME="country" SIZE=10>
<OPTION VALUE="US" SELECTED>United States
<OPTION>Sip Espresso
<OPTION>Afghanistan
<OPTION>Albania
<OPTION>Algeria
<OPTION>Andorra
<OPTION>Angola
<OPTION>Anguilla
<OPTION>Antigua and Barbuda
<OPTION>Argentina
<OPTION>Armenia
<OPTION>Aruba
<OPTION>Ashmore and Cartier Islands
<OPTION>Australia
<OPTION>Austria
<OPTION>Azerbaijan
<OPTION>Bahrain
<OPTION>Bangladesh
<OPTION>Barbados
<OPTION>Bassas da India
<OPTION>Belarus
<OPTION>Belgium
<OPTION>Belize
<OPTION>Benin
<OPTION>Bermuda
<OPTION>Bhutan
<OPTION>Bolivia
<OPTION>Bosnia and Herzegovina
<OPTION>Botswana
<OPTION>Bouvet Island
<OPTION>Brazil
<OPTION>British Indian Ocean Territory
<OPTION>British Virgin Islands
<OPTION>Brunei
<OPTION>Bulgaria
<OPTION>Burkina
<OPTION>Burma
<OPTION>Burundi
<OPTION>Cambodia
<OPTION>Cameroon
<OPTION>Canada
<OPTION>Cape Verde
<OPTION>Cayman Islands
<OPTION>Central African Republic
<OPTION>Chad
<OPTION>Chile
<OPTION>China
<OPTION>Christmas Island
<OPTION>Clipperton Island
<OPTION>Cocos (Keeling) Islands
<OPTION>Colombia
<OPTION>Comoros
<OPTION>Congo
<OPTION>Costa Rica
<OPTION>Cote d'Ivoire
<OPTION>Croatia
<OPTION>Cuba
<OPTION>Cyprus
<OPTION>Czech Republic
<OPTION>Denmark
<OPTION>Djibouti
<OPTION>Dominica
<OPTION>Dominican Republic
<OPTION>Egypt
<OPTION>El Salvador
<OPTION>Ecuador
<OPTION>Equatorial Guinea
<OPTION>Eritrea
<OPTION>Estonia
<OPTION>Ethiopia
<OPTION>Europa Island
<OPTION>Falkland Islands (Islas Malvinas)
<OPTION>Faroe Islands
<OPTION>Finland
<OPTION>France
<OPTION>French Guiana
<OPTION>French Southern and Antarctic Lands
<OPTION>Gabon
<OPTION>Gaza Strip
<OPTION>Germany
<OPTION>Georgia
<OPTION>Ghana
<OPTION>Gibraltar
<OPTION>Glorioso Islands
<OPTION>Greece
<OPTION>Greenland
<OPTION>Grenada
<OPTION>Guadeloupe
<OPTION>Guatemala
<OPTION>Guernsey
<OPTION>Guinea
<OPTION>Guinea-Bissau
<OPTION>Guyana
<OPTION>Haiti
<OPTION>Heard Island and McDonald Islands
<OPTION>Holy See (Vatican City)
<OPTION>Honduras
<OPTION>Hong Kong
<OPTION>Hungary
<OPTION>Iceland
<OPTION>India
<OPTION>Indonesia
<OPTION>Iran
<OPTION>Iraq
<OPTION>Ireland
<OPTION>Israel
<OPTION>Italy
<OPTION>Jamaica
<OPTION>Jan Mayen
<OPTION>Japan
<OPTION>Jersey
<OPTION>Jordan
<OPTION>Juan de Nova Island
<OPTION>Kazakhstan
<OPTION>Kenya
<OPTION>Korea, North-Eastern Asia
<OPTION>Korea, South-Eastern Asia
<OPTION>Kyrgyzstan
<OPTION>Kuwait
<OPTION>Laos
<OPTION>Latvia
<OPTION>Lebanon
<OPTION>Lesotho
<OPTION>Liberia
<OPTION>Libya
<OPTION>Liechtenstein
<OPTION>Lithuania
<OPTION>Luxembourg
<OPTION>Macau
<OPTION>Madagascar
<OPTION>Malaysia
<OPTION>Malawi
<OPTION>Maldives
<OPTION>Mali
<OPTION>Malta
<OPTION>Man, Isle of
<OPTION>Martinique
<OPTION>Mauritania
<OPTION>Mauritius
<OPTION>Mayotte
<OPTION>Mexico
<OPTION>Moldova
<OPTION>Monaco
<OPTION>Mongolia
<OPTION>Montserrat
<OPTION>Morocco
<OPTION>Mozambique
<OPTION>Namibia
<OPTION>Navassa Island
<OPTION>Nepal
<OPTION>Netherlands
<OPTION>Netherlands Antilles
<OPTION>New Caledonia
<OPTION>New Zealand
<OPTION>Nicaragua
<OPTION>Niger
<OPTION>Nigeria
<OPTION>Norway
<OPTION>Oman
<OPTION>Pakistan
<OPTION>Panama
<OPTION>Papua New Guinea
<OPTION>Paracel Islands
<OPTION>Paraguay
<OPTION>Peru
<OPTION>Philippines
<OPTION>Poland
<OPTION>Portugal
<OPTION>Puerto Rico
<OPTION>Qatar
<OPTION>Reunion
<OPTION>Romania
<OPTION>Russia
<OPTION>Rwanda
<OPTION>Saint Helena
<OPTION>Saint Kitts and Nevis
<OPTION>Saint Lucia
<OPTION>Saint Pierre and Miquelon
<OPTION>Saint Vincent and the Grenadines
<OPTION>San Marino
<OPTION>Sao Tome and Principe
<OPTION>Saudi Arabia
<OPTION>Senegal
<OPTION>Serbia and Montenegro
<OPTION>Seychelles
<OPTION>Sierra Leone
<OPTION>Singapore
<OPTION>Slovakia
<OPTION>Slovenia
<OPTION>Somalia
<OPTION>South Africa
<OPTION>South Georgia and the South Sandwich Islands
<OPTION>Spain
<OPTION>Spratly Islands
<OPTION>Sri Lanka
<OPTION>Sudan
<OPTION>Suriname
<OPTION>Svalbard
<OPTION>Swaziland
<OPTION>Sweden
<OPTION>Switzerland
<OPTION>Syria
<OPTION>Taiwan
<OPTION>Tajikistan
<OPTION>Tanzania
<OPTION>Thailand
<OPTION>The Bahamas
<OPTION>The Gambia
<OPTION>Togo
<OPTION>Trinidad and Tobago
<OPTION>Tromelin Island
<OPTION>Tunisia
<OPTION>Turkey
<OPTION>Turkmenistan
<OPTION>Turks and Caicos Islands
<OPTION>Uganda
<OPTION>Ukraine
<OPTION>United Arab Emirates
<OPTION>United Kingdom
<OPTION>United States
<OPTION>Uruguay
<OPTION>Uzbekistan
<OPTION>Vatican City (Holy See)
<OPTION>Venezuela
<OPTION>Vietnam
<OPTION>Virgin Islands
<OPTION>West Bank
<OPTION>Western Sahara
<OPTION>Yemen
<OPTION>The Former Yugoslav Republic of Macedonia
<OPTION>Zaire
<OPTION>Zambia
<OPTION>Zimbabwe
</SELECT> <P>
2) If you live in the United States, what state do you live in? <P>
<SELECT NAME="state" SIZE=7>
<OPTION VALUE="notUS" SELECTED> I do not live in the U.S.
List
</SELECT> <P>
3) Where do you live right now? (choose one) <P>
<OL>
<LI> <INPUT TYPE="radio" NAME="wherelive" VALUE="city" CHECKED> In a city
<LI> <INPUT TYPE="radio" NAME=" wherelive" VALUE="suburb"> In a suburb
<LI> <INPUT TYPE="radio" NAME="wherelive" VALUE="country"> In the country
<LI> <INPUT TYPE="radio" NAME="wherelive" VALUE=" Other"> Visa.
</UL>
</OL>
If other, please explain: <P>
<TEXTAREA NAME="liveoth" ROWS=3 COLS=60></TEXTAREA> <P>
4) I live (check as many as apply to you)<P>
<OL>
<LI> <INPUT TYPE="checkbox" NAME="live" VALUE="prison">
in a prison
<LI> <INPUT TYPE="checkbox" NAME="live" VALUE="reservation"> on a reservation
<LI> <INPUT TYPE="checkbox" NAME="live" VALUE="shelter">
in a shelter, group home, etc.
<LI> <INPUT TYPE="checkbox" NAME="live" VALUE="commune">
in a communal home
<LI> <INPUT TYPE="checkbox" NAME="live" VALUE="othplace">
other (please explain)
</OL>
If other, please explain: <P>
<TEXTAREA NAME="othplc" ROWS=3 COLS=60></TEXTAREA> <P>
5. When were you born? <p>
<TEXTAREA NAME="born" ROWS=1 COLS=4 VALUE="19"></TEXTAREA> <P>
6) What is your education level?
<SELECT NAME="education" SIZE=9>
<OPTION VALUE="US" SELECTED> I do not live in the U.S.
<OPTION>Less than 8 years of school
<OPTION>8 years
<OPTION>Some high school
<OPTION VALUE="highschool SELECTED> Graduated high school
<OPTION>Vocational training
<OPTION>Some college
<OPTION>College degree
<OPTION>Some graduate/professional school
<OPTION>Graduate/professional degree
</SELECT> <P>
2. Type of work
Professional
Managerial/official
Clerical
Craftsperson
Operative/unskilled worker (find new name)
Farmer
Service worker
Private Household worker
Worker status
Employed full time
Employed part time
Unemployed
Are you currently a student (any education level)?
Yes, full time
Yes, part time
No
What is your yearly income? (in US dollars)
Under $5000
$5000 to $9999
$10,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 or more
I do not know how to translate my income to US dollars.
My income in my currency is __________
Relationship Status
Primary relationship with a women
Primary relationship with a man
Primary relationships with both a woman and a man
Single, somewhat involved with a woman
Single, somewhat involved with a man
Single, somewhat involved with both a woman and a man
Single and uninvolved
Widowed from a partnership with a woman
Widowed from a partnership with a man
Number of people in household
Please check your race/ethnicity or type it in if it is not on this list.
Aleut
American Indian
Asian Indian
Asian (non-Indian)
Black, African, African-American (non-Hispanic)
Eskimo
Latina
Pacific Islander
White (non-Hispanic), Caucasian
Other
Height
Weight
Do you have any of the following problems now? Have you had any in the past? Are you getting treatment for any of them now? (check all the apply)
Lumps/growths in breast
Discharge from nipples
Lumps/growths around vagina (private area)
Rashes/sores around vagina
Very bad cramps with period
Heavy bleeding with period
Periods irregular or too often
Periods have stopped (not because of menopause)
Bleeding between periods
Unusual/bad smelling discharge (not during your period)
Premenstrual syndrome (PMS)
Cancer: What kind? __________________
Other: ______________________
Other: ______________________
Problem in the past
Problem now
Getting help
Check as many of the following as apply to the gynecological (female) problems above:
Where do you get treatment?
Private office
Community clinic
Women's health center
Health team at work
Public health department
Hospital emergency room
Botanica
HMO
Get no treatment
Other ____________________
Who treats you?
Medical doctor
Naturopathic doctor
Nurse
Nutrition counselor
Chiropractor
Herbalist
Spiritualist
Self
Seen no one
Other __________________
Where do you get the most treatment?
Who treats you the most often?
If you need help and are not getting it, why? (check all that apply)
Can take care of yourself
Family, friends take care of you
Don't know how to find help
Can't afford help
Am uncomfortable/embarrassed/afraid
Don't trust staff at places you know
Have had bad experiences at place you can go to
There's no place where the health care workers speak your language
Other ____________________________
In trying to get help for any of the above health problems, have you had any of the following experiences with health care workers? (check all that apply
They wouldn't listen to you
They told you the wrong things to do
They wouldn't tell you what was wrong
They didn't tell you what they were going to do
They are too rough physically
They are hard to talk to they really don't want to help you
They gave you treatment you didn't need
They assumed that you are straight
You felt uncomfortable when telling your sexual orientation
You did not tell your sexual orientation, although it may have been important
They tried to force birth control on you
They discriminated against you because of your race
Other ____________________
Other ____________________
Happens to you now
Used to happen but not anymore
How do you rate the care you have received for gynecological (female) problems in the past ?
Very good
Good
Fair
Poor
How do you rate the care you are receiving for gynecological (female) problems now?
Very good
Good
Fair
Poor
Have you ever been pregnant?
Yes
No
Have you ever given birth?
Yes
No
How many children have you had?
Have you had any of the following? (check all that apply)
Hysterectomy
Abortion
Miscarriage
Stillbirth
If you haven't been pregnant, have you ever wanted to be?
What, if anything, has kept you from becoming pregnant?
If you want to become a parent, would you try any of the following? (check all that apply)
I do not wish to become a parent
Having sex with a man
Adoption
Co-parenting
Artificial insemination (donor insemination) by a known donor
Artificial insemination (donor insemination) by an unknown donor
Artificial insemination (donor insemination) through a sperm bank
Add information if you want to
Have you had a pap smear (also known as a cervical smear)...
Within the last year?
Within the last 2 years?
Within the last 3 years?
Within the last 10 years?
More than 10 years ago?
Never
Do you examine your breasts for lumps
Every month?
Once every few months
About once a year?
Never?
Other ___________________
Are you going through menopause (change of life)?
If so, are you using any of the following? (check all that apply)
Hormone treatment
Nutritional treatment
Herbal treatment
Other _____________________
Add information if you want to _____________________
Do you worry about getting sexually transmitted diseases?
Does fear of disease keep you from doing some sex acts?
Add information if you want to
Where would you turn most often for information about sexually transmitted diseases?
Lover
Friends
Family
Private health care workers
Public clinics
Gay center / organization
Health / medical journals
Books
Gay magazines / newspapers
Other magazines / newspapers
Hotline
Other _________________
Where did you find out about this survey?
Lesbian Chat Galore
A mailing list I am on
A friend told me about it
I saw something about it on another page.
I just happened across it
Other ____________________
To submit your choices, press this button: <INPUT TYPE="submit"
VALUE="Submit Choices">. <P>
To reset the form, press this button: <INPUT TYPE="reset" VALUE="Reset">.
</FORM>
A small text box
And a text entry form: <INPUT NAME="entry" SIZE=30> <P>
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