African American Family Referral Survey

DATE:  
Family Surname or Last name ONLY
Email
Your City
State 
Zip
What is Your age? 18-28    29-40    41-60    61-75    over75
Are you? Male        Female   
African American  yes        no
Have you ever attended a health fair and gotten screened?
Yes    No
Which screening do you plan to have this week at the health fair?
  Diabetes          Blood Pressure          Prostate Cancer          HIV Aids
Do you plan to visit the Montel Williams Partnership for Prescription Assistance (PPA) Van outside the Convention Center to get information about how to get free and discounted prescriptions:
Yes        No
Does your church have a Health Ministry  
Yes        No
If Yes, have you ever attended a Health fair at your church or one in partnership with other churches in your city?
    Yes                  No 
If No, Would you be interested in attending and bringing friends and family to a health fair at your church or one in partnership with other churches in your city?
  Yes                 No
Do you think there are things you could do to live healthier?
  YES                  NO       
  If yes: 

Get more exercise
Drink more water
Get regular medical check-ups
Do better at taking my medications
Learn more about different diseases which affect my race
Have you or a family member been diagnosed with any of the following ?
  Self      Family Member
Diabetes  
High Blood Pressure
Asthma  
Heart Disease
HIV-AIDS
Prostate Cancer
Breast Cancer
Colon Cancer 
Kidney Cancer
Obesity   
Do you smoke?     Yes   No   

Regarding Clinical Trials
How safe do you believe are clinical trials today
Very safe
Somewhat safe
Not very safe
Not safe at all
Why do you think such small numbers of African Americans take part in clinical trials?

Not enough black physicians
No one asked
Health risks
Tuskegee
Not enough education provided about clinical trials
Would you be more likely to participate in a clinical trial if it were:

Conducted by a Government agency
Conducted by a Pharmaceutical company
Does not matter
Need more education
Would not take part under any circumstances

NPFR Affiliate Programs

CBO Coalition: if you are a member of an African American organization with health focused activities, and would be interested in partnering with 50 Hoops or NPFR for an event in your city

 
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