Demographic Questions
1. Athlete’s First Name (first):
2. Athlete’s Surname (first):

3. Please choose an age group.
 

4. What community do you live closest to:
 

5. Who is answering this survey?
 


Lifestyle & Programming Questions

6. Considering your health experience indicate which of the following options are true for you?

Check the box beside the condition(s) you currently experience:

It costs too much to eat healthy
 

It's difficult to get transportation so I can go to programs or activities.
 

I haven't found a healthcare professional I can trust trust.
 

Communicating with healthcare professional.
 

Finding a support group to help me with my goals has been hard
 

I'm happy with my health experience
 
6b. Other:


7. Check the 3 most important things that you would change in your lifestyle to be healthier
7b. Other:


8. Do you currently participate in Special Olympics PEI Wellness Programs?
 


9. What programs would you like to attend in your community if they were available:
9b. Other:


10. Check the following activities you would do if they were available:


11. Would you participate in a monthly health and wellness workshop if it was offered in your area?
 



12. Have you heard about the Special Olympics PEI Healthy Communities project?
 



Healthy Athlete Screening & Healthcare Professionals



Special Smiles

13. Do you have a dentist that you see regularly?
 
13a. If you answered yes, How often do you visit the dental clinic?
13b. When did you last get your teeth checked?
13c. What is the name of your dentist?
13d. If you answered no, please check which reasons fit best.
13i. Other:



Fit Feet

14 Do you have a Podiatrist (Foot Specialist) you see regularly?
 
14a. If you answered yes, How often do you visit the podiatrist?
14b. When did you last get your feet checked?
14c. What is the name of your podiatrist?
14d. If you answered no, please check which reasons fit best.
14k. Other:



Healthy Hearing

15. Have you ever been to an Audiologist for your hearing?
 
15a. If you answered yes, How often do you visit the Audiologist?
15b. When did you last get your hearing checked?
15c. What is the name of your Audiologist?
15d. If you answered no, please check which reasons fit best.
15k. Other:



Opening Eyes

16. Do you have an Optometrist (Eye Doctor) you see regularly?
 
16a. If you answered yes, How often do you visit the Optometrist?
16b. When did you last get your vision checked?
16c. What is the name of your Optometrist?
16d. If you answered no, please check which reasons fit best.
16k. Other:



MedFest

17. Do you have a Doctor you see regularly?
 
17a. If you answered yes, How often do you visit the Doctor?
17b. When did you last get a medical check-up?
17c. What is the name of your Doctor?
17d. If you answered no, please check which reasons fit best.
17j. Other:



Health Promotion

18. Have you ever been to a Dietitian for meal planning?
 
18a. If you answered yes, How often do you visit the Dietitian?
18b. When did you last visit the Dietitian?
18c. What is the name of your Dietitian?
18d. If you answered no, please check which reasons fit best.
18k. Other:



Strong Minds

19. Do you see a Psychologist or Mental Health trainer often?
 
19a. If you answered yes, How often do you visit a Psychologist or Mental Health trainer?
19b. When did you last see them?
19c. What is the name of your Psychologist or Mental Health trainer?
19d. If you answered no, please check which reasons fit best.
19k. Other:



Fun Fitness

20. Do you have a Physiotherapist or Occupation Therapist (Body/Joint/Movement Specialist) you see regularly?
 
20a. If you answered yes, How often do you visit a Physiotherapist or Occupation Therapist?
20b. When did you last see them?
20c. What is the name of your Physiotherapist or Occupation Therapist?
20d. If you answered no, please check which reasons fit best.
20k. Other:


Thank you for completing this survey!


 

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