Please answer the questions below with the best answer or answers. Responses are strictly anonymous.

Upon submitting the survey, you will be directed to a second page with a submit button. Clicking that submit button will take you to a form to enter a drawing for a $25 gift card from Walmart in appreciation for completing the survey. Information submitted for the raffle is separate from the survey.

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* 1. Where do you live?

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* 2. What do you think are the most important health factor issues that affect health in our community? (Please check all that apply)

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* 3. What do you think are the most important health condition or outcome issues that affect health in our community? (Please check all that apply)

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* 4. Which health care services are hard to get in our community? (Please check all that apply)

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* 5. Which social / support resources are hard to get in our community? (Please check all that apply)

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* 6. What keeps you from being healthy? (Please check all that apply)

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* 7. Do you use medical care services?

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* 8. Please check all the medical care services you use.

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* 9. How long has it been since you last visited a doctor or other healthcare provider for a routine checkup? 

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* 10. Do you use dental care services?

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* 11. Please check all the dental care services you use.

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* 12. How long has it been since you last visited a dentist or dental clinic for any reason? Include visits to dental specialists such as orthodontists. 

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* 13. Do you use mental health, alcohol use, or drug use services?

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* 14. Please check all the Do you use mental health, alcohol use, or drug use services? you use.

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* 15. How long has it been since you last used mental health, alcohol use, or drug use services for any reason?

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* 16. Have you been told by a doctor that you have… (Please check all that apply)

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* 17. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (Please indicate number of days in box below)

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* 18. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (Please indicate number of days in box below)

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* 19. During the past 30 days: (Please check all that apply)

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* 20. I have been to the emergency room in the past 12 months.

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* 21. I have been to the emergency room for an injury in the past 12 months (e.g., motor vehicle crash, fall, poisoning, burn, cut, etc.).

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* 22. I have been a victim of domestic violence or abuse in the past 12 months.

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* 23. I take the medicine my doctor tells me to take to control my chronic illness.

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* 24. I can afford medicine needed for my health conditions.

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* 25. Does your community support physical activity? (e.g., parks, sidewalks, bike lanes, etc.)

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* 26. In the area that you live, is it easy to get affordable fresh fruits and vegetables?

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* 27. Have there been times in the past 12 months when you did not have enough money to buy the food that you or your family needed?

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* 28. Have there been times in the past 12 months when you did not have enough money to pay your rent or mortgage?

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* 29. Do you feel safe where you live?

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* 30. In the past 7 days, how many days were you physically active for a total of at least 30 minutes? (Add up all the time you spend in any kind of physical activity that increased your heart rate and made you breathe hard for some of the time.)

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* 31. Where do you get the food that you eat at home? (Please check all that apply)

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* 32. During the past 7 days, how many times did you eat fruit and vegetables? Do not count fruit or vegetable juice. (Please check one)

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* 33. In the past 7 days, how many times did all or most of your family living in your house eat a meal together?

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* 34. How connected do you feel with the community and those around you?

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* 35. Where do you sleep most often? (Please check one)

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* 36. Do you have access to reliable transportation?

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* 37. What type of transportation do you use most often?

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* 38. Which of the following describes your current type of health insurance? (Please check all that apply)

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* 39. If you have no health insurance, why don’t you have insurance? (Please check all that apply)

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* 40. What is your Zip Code? (Indicate in box below)

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* 41. What is your age? (Indicate in the box below)

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* 42. What is your gender identity?

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* 43. What is your height? (Indicate feet in first box and inches in second box)

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* 44. What is your weight? (Indicate in pounds below)

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* 45. How many people live in your home (including yourself)?

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* 46. What is your highest education level completed?

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* 47. What race/ethnicity do you identify with? (Please check one)

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* 48. What is your marital status?

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* 49. What is your yearly household income?

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* 50. What is your current employment status?

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* 51. Is there anything else we should know about your (or someone living in your home) needs to stay healthy?

0 of 51 answered
 

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