Buffalo Trace Regional Health and Wellness Survey, Spring 2011

Please take a few minutes to complete the survey for us.

Your responses are strictly confidential and their origin cannot be traced.

1. Please type your County of Residence in the box below

Please type your County of Residence in the box below

2. What is your age group?

What is your age group? Under 21

21-30

31-40

41-50

51-60

61-70

Above 70

3. How would you rate the Overall Health of your County?

How would you rate the Overall Health of your County? Very Unhealthy

Unhealthy

Somewhat Healthy

Healthy

Very Healthy

4. How would you rate your County as a “Safe County?”

How would you rate your County as a “Safe County?” Very Unsafe

Unsafe

Somewhat safe

Safe

Very Safe

5. How would you rate your own personal health?

How would you rate your own personal health? Very Unhealthy

Unhealthy

Somewhat Healthy

Healthy

Very Healthy

6. How would you rate your own personal safety?

How would you rate your own personal safety? Very Unsafe

Unsafe

Somewhat Safe

Safe

Very Safe

7. From the following list, what do you think are the 3 most needed to improve the well being in your county? (Those things which most improve the quality of life in your county) PLEASE CHOOSE ONLY 3

From the following list, what do you think are the 3 most needed to improve the well being in your county? (Those things which most improve the quality of life in your county) PLEASE CHOOSE ONLY 3 Good place to raise children

Low crime/safe neighborhood

Low level of child abuse

Good schools

Access to health care (e.g. family doctor)

Parks and recreation

Clean environment

Affordable housing

Arts and cultural events

Excellent race relations

Good jobs and healthy economy

Strong family life

Healthy behaviors and lifestyles

Low adult death and disease rates

Low infant deaths

Religious or spiritual values

Quality child care

Other (please specify in the box below)

8. From the following list, what do you think are the 3 greatest health problems in your county? (Those problems which have the greatest impact on overall county health) PLEASE CHOOSE ONLY 3

From the following list, what do you think are the 3 greatest health problems in your county? (Those problems which have the greatest impact on overall county health) PLEASE CHOOSE ONLY 3 Aging problems (e.g. arthritis,Hearing / vision loss, etc.) Cancers Child abuse / neglect Dental problems Infectious Diseases (e.g.,hepatitis, TB, etc.) Mental health problems Heart disease and stroke	High blood pressure HIV / AIDS Homicide Infant death Suicide Teenage pregnancy Alcohol/Drug abuse	Motor vehicle crash injuries Rape / sexual assault Respiratory / lung disease Sexually Transmitted Diseases Diabetes Domestic violence Firearm-related injuries
Other (please specify in the box below)

9. From the following list, what do you think are the 3 most risky behaviors in your county? (Those behaviors which have the greatest impact on overall county health) PLEASE CHOOSE ONLY 3

From the following list, what do you think are the 3 most risky behaviors in your county? (Those behaviors which have the greatest impact on overall county health) PLEASE CHOOSE ONLY 3 Alcohol abuse Being overweight Dropping out of school Drug abuse Lack of exercise Poor eating habits	Not getting “shots” to prevent disease Racism Tobacco use Not using birth control Not using seat belts/child safety seats Unsafe sex
Other (please specify in the box below)

10. In general, how satisfied are you with the overall quality of life in your own neighborhood?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how satisfied are you with the overall quality of life in your own neighborhood? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

11. In general, how would you describe your neighborhood as a place to raise children?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10=Best	In general, how would you describe your neighborhood as a place to raise children? 1= Worst and 10=Best 1	1= Worst and 10=Best 2	1= Worst and 10=Best 3	1= Worst and 10=Best 4	1= Worst and 10=Best 5	1= Worst and 10=Best 6	1= Worst and 10=Best 7	1= Worst and 10=Best 8	1= Worst and 10=Best 9	1= Worst and 10=Best 10

12. In general, how would you describe your neighborhood as a place to grow old?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how would you describe your neighborhood as a place to grow old? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

13. In general, how would you describe the accessibility of health services for the aging in your county?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how would you describe the accessibility of health services for the aging in your county? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

14. In general, how would you describe the quality of services for the aging in your county?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how would you describe the quality of services for the aging in your county? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

15. In general, how would you describe the accessibility of healthcare in your county?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how would you describe the accessibility of healthcare in your county? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

16. In general, how would you describe the affordability of health care in your county?

	1	2	3	4	5	6	7	8	9	10
1= Worst and 10= Best	In general, how would you describe the affordability of health care in your county? 1= Worst and 10= Best 1	1= Worst and 10= Best 2	1= Worst and 10= Best 3	1= Worst and 10= Best 4	1= Worst and 10= Best 5	1= Worst and 10= Best 6	1= Worst and 10= Best 7	1= Worst and 10= Best 8	1= Worst and 10= Best 9	1= Worst and 10= Best 10

Thank you for taking the time to complete this survey.
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