* 1. In your opinion, what is the health related issue that most people die from in your community?

* 2. In your opinion, what is the biggest health issue or concern in your community?

* 3. In your opinion, what do you think is the main reason people in your community do not seek medical care?

* 4. In your opinion, which factor most affects the quality of health care you or people in your community receive?

* 5. In your opinion, which of the following do you feel people in your community lack the funds to purchase?

* 6. Which of the following does your community need in order to improve the health of your family, friends, and neighbors?

* 7. Which of the following are problems for you and/or your family?

* 8. What health screenings or education/information services are needed the most in your community?

* 9. Where do you or your family receive most of your health information?

* 10. When seeking care, which hospital would you visit first?

* 11. Which of the following healthy lifestyle habits do you incorporate into your daily living?

* 12. Please select your gender

* 13. Please select your age

* 14. My zip code is

* 15. I live in

* 16. My racial/ethnic identification is

* 17. Community Representation

* 18. What do you perceive as the most important problems facing the community in the health care services area?

* 19. What can a hospital do to improve the quality of life in the community?

* 20. What is your vision for a healthy community?

* 21. We appreciate any comments you may have about this survey or health needs in your community.

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