Buffalo Trace Regional Health and Wellness Survey, Spring 2011

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

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2. What is your age group?

Under 21

21-30

31-40

41-50

51-60

61-70

Above 70

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

Very Unhealthy

Unhealthy

Somewhat Healthy

Healthy

Very Healthy

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

Very Unsafe

Unsafe

Somewhat safe

Safe

Very Safe

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5. How would you rate your own personal health?

Very Unhealthy

Unhealthy

Somewhat Healthy

Healthy

Very Healthy

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6. How would you rate your own personal safety?

Very Unsafe

Unsafe

Somewhat Safe

Safe

Very Safe

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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

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)

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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

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)

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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

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)

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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	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

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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	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

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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	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

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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	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

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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	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

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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	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

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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	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

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