* 2. My zip code is:

* 3. I have this type of health care coverage:

* 4. I think these are the 3 most important health concerns on our community:

* 5. I think these are the 3 most important factors for a healthy community:

* 6. I would rate the overall health of our community as:

* 7. Age

* 8. Gender

* 9. Which race/ethnic group do you most identify with? (Choose only one)

* 10. Are you of Hispanic, Latino or Spanish origin?

* 11. My Job Status

* 12. My household income (in $) is:

* 13. Highest level of education

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