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Chiropody Client Survey-English

Champlain Diabetes Chiropody Program Survey

Part A:  Questions about you
1. A1. You identify as
2. A2. Age group
3. A3. Language spoken most often at home?
4. A4. Ethnic/Cultural Group
5. A5. Is this your first visit to the Chiropody program?
6. A6. At which location do you usually get services? Please check one box: