WSHC Community Baseline 2010
Exit this survey
Please answer the following 16 questions.
1
. About You: Demographic Information
Age
Under 18
18-25
26-35
36-45
46-55
56+
About You: Demographic Information Age
2
. Location
Gustine
Newman
Patterson
Other
Location
3
. Gender
Male
Female
Gender
4
. How often do you eat out?
Daily
2-3 times week
2-3 times month
Rarely
Never
How often do you eat out?
5
. How often do you include fresh fruits and vegetables in your meals?
Daily
2-3 times week
Once per week
Never
How often do you include fresh fruits and vegetables in your meals?
6
. Do you consider healthy choices (nutrition) when you shop for groceries?
Yes
No
Do you consider healthy choices (nutrition) when you shop for groceries?
7
. If no, is it because of...
Cost
I don't like these types of foods
Lack of preparation ideas
If no, is it because of...
8
. Do you smoke?
Yes
No
Do you smoke?
9
. How often do you think about your health?
Daily
One or more times a week
Couple times a month
Rarely
Never
How often do you think about your health?
10
. How often do you exercise?
Daily
2-3 times week
Once per week
Rarely
Never
How often do you exercise?
11
. If you exercise, how do you get your exercise?
If you exercise, how do you get your exercise?
Walk
At work
Running
Hobbies/Sports
Other
Other (please specify)
12
. How healthy would you rate your present state of body? [1 = Not healthy / 5 = Very healthy)
1
2
3
4
5
How healthy would you rate your present state of body? [1 = Not healthy / 5 = Very healthy)
13
. Do you or your family members regularly visit a doctor when you need to?
Yes
No
Do you or your family members regularly visit a doctor when you need to?
14
. If no, why?
No insurance
Cost
Can't get appointment
No transportation
If no, why?
15
. Have you heard about the Healthy Choices Campaign for the West Side?
Yes
No
Have you heard about the Healthy Choices Campaign for the West Side?
16
. If yes, how?
If yes, how?
Newspaper Article
Newspaper Ad
Newsletter
Flier
Word of Mouth
17
. What are some ways in which messages about healthy life style choices could be shared with you and your community?
What are some ways in which messages about healthy life style choices could be shared with you and your community?
Newspaper
Internet letter
Radio
Billboard
Direct mailing
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