* 1. Do you live in Alexander County?

* 2. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

* 3. How old are you? (Mark age category)

* 4. What is your sex?

* 5. Which of the following would you say is your race? (Check only one)

* 6. What is the highest level of school, college or vocational training that you have finished? (Check only one)

* 7. What was your TOTAL household income last year, before taxes?

* 8. How many people does this income support? (If you are paying child support but your child is not living with you, this still counts as someone living on your income.) (Please write a number)

* 9. What is your employment status?

* 10. What is your main source of transportation?

* 11. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health NOT good?

* 12. Thinking about your mental health, which includes stress, depression/feelings of sadness, and problems with emotions, for how many days during the past 30 days was your mental health NOT good?

* 14. Where do you most often seek medical care?

* 15. About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness or condition.

* 16. When was the last time you went to the dentist?

* 17. What are your reasons for seeking medical care outside of Alexander County? (Select all that apply)

* 18. Please select the top 3 health concerns that are important to you.

* 19. Does Alexander County need improvement in regards to the following issues? (Choose 4 answers)

* 20. In your community do you know where the following resources are located?

  Yes No Unsure Not Available
Legal assistance
Help with childcare or after-school care
Adult daycare/elderly care
Individual or family counseling
Help coping with domestic violence
Physically or mentally handicapped services
Immunization services
Free or reduced-cost health care

* 21. Do you have any health care coverage, such as health insurance or government plans, such as Medicaid or Medicare?

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