* 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.