( ) Under $15,000 ( ) $15-24,999
( ) $25-34,999 ( ) $35-49,999
5. What is your animated arrangement (residence)?
( ) House ( ) Public shelter
6. What is your living arrangement (partner)?
( ) hook up with ( ) Single, never married
( ) Significant other ( ) Divorced or widowed
7. Are their children in your household?
8. How many persons are in your household?
( ) 1 ( ) 2 ( ) 3
9. What is your ethnic or racial background?
( ) African American ( ) Asian American
( ) Hispanic ( ) primordial Amer
dietary restrictions associated with your treatment
( ) slight regimen ( ) Long regimen
( ) Very important ( ) Important
13. Do you take your prescribed medications daily or as
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