Adult Survey

The greatness of a community is truly measured by the kind actions of its members.
-In reference to Coretta Scott King
 
We appreciate your time in completing the Community Health Assessment (CHA) survey. This survey provides valuable input from community members about their current health situations, needs, and issues that public health can then study and find ways to improve.
Directions
We want to assure you that your individual responses to the survey are completely private. Responses to the survey cannot be traced back to you.
Please fill out survey to the best of your knowledge.

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* 1. Do you currently live in Iredell County? If you do NOT live in Iredell County you do not need to complete this survey.

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* 2. In what city/town do you live?

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* 3. What is your zip code?

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* 4. What is your gender?

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* 5. What is your age?

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* 6. Please select the race or ethnicity that best fits you.

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* 7. How would you describe your living arrangement?

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* 8. What is your annual household income?

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* 9. What is your main source of transportation?

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* 10. How would you describe your weight?

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* 11. Have you been diagnosed with any of the following? (Select all that apply)

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* 12. Have you ever had any of the following? (Select all that apply)

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

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* 14. When was the last time you had a routine physical?

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

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* 16. Do you have health insurance?

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* 17. How often do you exercise for at least 150 minutes per week (2 ½ hours)?

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* 18. How many servings of fruits and vegetables do you normally eat in one day?

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* 19. What makes it hard for you to eat healthy? (Select all that apply)

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* 20. How often does your household run out of food before you have money to buy more?

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* 21. What do you think makes it hard for you to be physically active?

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* 22. How many hours each day do you spend inactive?

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* 23. How often do you drink any of the following? (example: regular soft-drinks/soda, diet soft-drinks/soda, drink mix, juice, energy drinks, etc.)

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* 24. If over 50, have you had a colonoscopy?

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* 25. If male over 50, do you have an annual prostate exam?

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* 26. If female over 40, do you have an annual mammogram?

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* 27. If female, do you have a pap smear when recommended?

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* 28. If female, do you preform monthly, breast self- exams?

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* 29. Do you use electronic cigarettes/vape products?

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* 30. Do you use tobacco products?

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* 31. Do you drink alcohol in excess?

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* 32. Do you misuse prescription medication?

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* 33. Do you use illegal drugs?

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* 34. Do you use protection against sexually transmitted diseases in your relationship?

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* 35. Do you drink alcohol and drive?

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* 36. Do you text and drive?

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* 37. Please circle the top 3 health concerns that are important to you.

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* 38. Does Iredell County need improvement in regards to any of the following issues? (Select all that apply)

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* 39. Where do you get most of your health-related information?

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* 40. Could you help someone in need to find the following in Iredell County? (Select all that apply)

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* 41. Does your household have the following items to make up a disaster supply kit? (Select all that apply)

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* 42. Do you know where in your community to locate the following resources during/ after an emergency or natural disaster? (Select all that apply)

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* 43. What would be your main method or way of getting information from authorities in a large-scale disaster or emergency? (Examples: severe weather, radiation exposure, etc.)

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* 44. What would be the main reason you might not evacuate, if asked to do so? (Select up to 3 answers)

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* 45. Does your home have a working smoke detector?

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* 46. Does your home have a working Carbon Monoxide Detector?

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* 47. Do you feel an emergency or natural disaster is likely to happen in Iredell County?

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* 48. Is there a member in your household that would need special assistance during an emergency or disaster?

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* 49. Do you have a person living in your home who has the following medical needs, if so, please choose your selection/s?

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* 50. I believe the following issues exist in Iredell County. Please choose your selection/s.

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* 51. Do you feel your safety is well protected by the following? Please choose your selection/s.

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* 52. Is your pet (dog, cat, or ferret) up-to-date on their rabies vaccine?

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* 53. Where do you go to get your pet vaccinated?

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* 54. If you’re a familiar with any of the choices below, please choose your selection/s.

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* 55. In the past 12 months, have you lived without one or more essential utilities (i.e., water, electricity, gas) in your home?

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* 56. How many people live with you?

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* 57. Has your child ever gone to bed hungry in the past 12 months?

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* 58. Are there things in your home you can’t use because it doesn’t work (i.e., bathroom faucet, toilet, or shower)?

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* 59. Does anyone who is not related to you by blood, marriage (stepfamily), or adoption live with you?

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* 60. Do you have a child or children under the age of 12 living in your home? If no, do not complete.

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* 61. In general, would you say your child’s (children’s) health is….

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* 62. How often does your child (children) visit the dentist?

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* 63. How many hours each day is your child (children) sedentary (example: working at a desk, watching TV, playing video games, etc.)? Please choose your selection/s.

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* 64. How often does your child (children) drink the following? (example: regular soft-drinks/sodas, diet soft-drinks/sodas, drink mix, juice, energy drinks, etc.)

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* 65. How often is your child (children) physically active for at least 60 minutes each day?

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* 66. How many servings of fruit and vegetables does your child (children) normally consume?

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* 67. Has your child (children) experienced bullying?

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* 68. Can you easily access affordable developmental services, such as daycare or afterschool care, to prepare your child for success?

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* 69. Do you feel your child has access to the following, anywhere? Please choose your selection/s.

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* 70. Has your child been exposed to cigarette smoke in your home?

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* 71. Have you ever heard of Sudden Infant Death Syndrome (SIDS) also called crib death?

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* 72. Did anyone ever talk to you about the safest place to put your infant down to sleep?

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* 73. How have you laid your infant down to sleep?

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* 74. What items do you have in the place where the baby sleeps now? Select all that apply.

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