If you have one of those diseases or conditions, please take a moment to share your experience. Sharing your experience can help others to better understand the importance of prevention. All identifying information will be kept completely confidential (unless you give us permission to release it—see below). Which disease or condition do you suffer from? Check all that apply.   heart disease   stroke   osteoporosis   type 2 diabetes   obesity   cancer   high blood pressure   high cholesterol How has your illness affected your life? Please describe what steps, such as taking medication or undergoing surgery or chemotherapy, you must take to control or cure your disease. Have you had to change your lifestyle/habits or take other steps because of your health? Yes    No   Please explain: Do you experience any symptoms, pain, or inconveniences because of your condition/illness? Yes    No   Please explain: Has your illness resulted in any extra medical bills? Has it affected your job or ability to work in any way? Yes    No   Please explain: How would you rate your eating habits before you were diagnosed? Good    Not so good   Please explain: Were you physically active before you were diagnosed? Yes    No   Please explain: Is there anything else you would like us to know? Would you be willing to speak to or have your experience shared with the press, the public, or lawmakers? Yes    No   Please explain: Thank you for taking the time to help us and others understand what it is like to live with your disease or condition. Please fill out the information below for our records. Rest assured that we will not release your name or other identifying information without getting your permission. If you have agreed to speak to the press, the public, or lawmakers, we will contact you if there is an opportunity for you to share your experiences. Your name: Age: Gender: Male:   Female: City: State: --USA-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY --CAN-- AB BC MB NB NF NT NS NU ON PE QC SK YT E-mail: Phone Number:

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