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Demographic Questions
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1. Athlete’s First Name (first): |
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2. Athlete’s Surname (first): |
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3. Please choose an age group. |
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4. What community do you live closest to: |
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5. Who is answering this survey?
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Lifestyle & Programming Questions
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6. Considering your health experience indicate which of the following options are true for you?
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Check the box beside the condition(s) you currently experience:
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6b. Other: |
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7. Check the 3 most important things that you would change in your lifestyle to be healthier |
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7b. Other: |
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8. Do you currently participate in Special Olympics PEI Wellness Programs?
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9. What programs would you like to attend in your community if they were available: |
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9b. Other: |
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10. Check the following activities you would do if they were available: |
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11. Would you participate in a monthly health and wellness workshop if it was offered in your area?
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12. Have you heard about the Special Olympics PEI Healthy Communities project?
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Healthy Athlete Screening & Healthcare Professionals
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Special Smiles
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13. Do you have a dentist that you see regularly?
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13a. If you answered yes, How often do you visit the dental clinic? |
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13b. When did you last get your teeth checked? |
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13c. What is the name of your dentist? |
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13d. If you answered no, please check which reasons fit best. |
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13i. Other: |
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Fit Feet
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14 Do you have a Podiatrist (Foot Specialist) you see regularly?
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14a. If you answered yes, How often do you visit the podiatrist? |
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14b. When did you last get your feet checked? |
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14c. What is the name of your podiatrist? |
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14d. If you answered no, please check which reasons fit best. |
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14k. Other: |
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Healthy Hearing
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15. Have you ever been to an Audiologist for your hearing?
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15a. If you answered yes, How often do you visit the Audiologist? |
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15b. When did you last get your hearing checked? |
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15c. What is the name of your Audiologist? |
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15d. If you answered no, please check which reasons fit best. |
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15k. Other: |
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Opening Eyes
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16. Do you have an Optometrist (Eye Doctor) you see regularly?
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16a. If you answered yes, How often do you visit the Optometrist? |
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16b. When did you last get your vision checked? |
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16c. What is the name of your Optometrist? |
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16d. If you answered no, please check which reasons fit best. |
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16k. Other: |
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MedFest
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17. Do you have a Doctor you see regularly?
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17a. If you answered yes, How often do you visit the Doctor? |
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17b. When did you last get a medical check-up? |
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17c. What is the name of your Doctor? |
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17d. If you answered no, please check which reasons fit best. |
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17j. Other: |
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Health Promotion
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18. Have you ever been to a Dietitian for meal planning?
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18a. If you answered yes, How often do you visit the Dietitian? |
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18b. When did you last visit the Dietitian? |
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18c. What is the name of your Dietitian? |
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18d. If you answered no, please check which reasons fit best. |
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18k. Other: |
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Strong Minds
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19. Do you see a Psychologist or Mental Health trainer often?
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19a. If you answered yes, How often do you visit a Psychologist or Mental Health trainer? |
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19b. When did you last see them? |
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19c. What is the name of your Psychologist or Mental Health trainer? |
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19d. If you answered no, please check which reasons fit best. |
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19k. Other: |
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Fun Fitness
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20. Do you have a Physiotherapist or Occupation Therapist (Body/Joint/Movement Specialist) you see regularly?
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20a. If you answered yes, How often do you visit a Physiotherapist or Occupation Therapist? |
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20b. When did you last see them? |
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20c. What is the name of your Physiotherapist or Occupation Therapist? |
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20d. If you answered no, please check which reasons fit best. |
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20k. Other: |
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Thank you for completing this survey! |
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