1. When did you last have a routine medical checkup (physical exam)? Less than 1 year ago1 to less than 2 years ago2 to less than 5 years ago5 or more years agoNever had oneDon’t know / Not sure
2. When did you last see your dentist or have a routine dental checkup? Less than 1 year ago1 to less than 2 years ago2 to less than 5 years ago5 or more years agoNever been to a dentistDon’t know / Not sure
3. When did you last see an eye doctor or have a routine eye exam? Less than 2 years ago2 to less than 3 years ago3 to less than 5 years ago5 or more years agoNever had eyes checkedDon’t know / Not sure
4. When did you last have a Pap test to screen for cervical cancer? Less than 3 years ago3 to less than 4 years ago4 to less than 5 years ago5 or more years agoNever had one / Not applicableDon’t know / Not sure
5. When did you last have a mammogram to screen for breast cancer? Less than 2 years ago2 to less than 3 years ago3 to less than 5 years ago5 or more years agoNever had one / Not applicableDon’t know / Not sure
6. Have you ever had a colonoscopy to screen for colon and rectal cancer? YesNoDon’t know / Not sure
7. Have you ever had a bone mineral density (BMD) test to screen for osteoporosis? YesNoDon’t know / Not sure
8. Have you ever had your fasting blood glucose (blood sugar) level checked for diabetes? YesNoDon’t know / Not sure
9. When did you last have your blood pressure checked? Less than 2 years ago2 to less than 3 years ago3 to less than 5 years ago5 or more years agoNever had it checkedDon’t know / Not sure
10. When did you last have your cholesterol checked? Less than 2 years ago2 to less than 3 years ago3 to less than 5 years ago5 or more years agoNever had it checkedDon’t know / Not sure
11. During the past 12 months, have you had a flu shot (influenza vaccine)? YesNoDon’t know / Not sure
12. Have you ever had a pneumonia shot (pneumococcal vaccine)? YesNoDon’t know / Not sure
13. What is your height without shoes? feet inches
14. What is your weight without shoes? pounds
15. In general, how would you classify your overall health? ExcellentVery goodGoodFairPoorDon’t know / Not sure
16. Do you have health insurance coverage? YesNoDon’t know / Not sure
17. Where do you work? Business or private sectorSelf employedState agencyStudent or homemakerRetired state employeeRetired (NOT former state employee)OtherNot applicable / Not working
18. Are you a Connecticut resident? YesNo