The Partnership for Healthy Communities is working with leaders in the area to learn more about your healthcare needs and the factors that impact your health. Please answer the following questions with the best answer or answers. All surveys will be KEPT CONFIDENTIAL. Thank you for taking the time to complete this survey. You must be over 18 years of age to complete this survey. Please complete this survey only once. The estimated time to complete this survey is 15 minutes. At the end of the survey, you may enter a drawing for a $25 gift card as our appreciation for your participation in this important project.

* 1. ENTRY CODE: FOR OFFICE USE ONLY

* 2. Is there a specific doctor's office, health center, or another place that you usually go if you are sick or need advice about your health? If you answer 'Yes' answer Question 3; If you answer 'No' skip to Question 4.

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