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* 1. Today's date

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* 2. What's your age?

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* 3. Are you able to work?

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* 4. What is your employment status?

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* 5. If unemployed are you currently looking for work?

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* 6. Would you like help with these job related activities? Check all that apply.

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* 7. Do you have access to the Internet? If No skip the next question.

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* 8. Where do you usually use the internet? Check all that apply.

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* 9. What's your Zip code?

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* 10. How would you describe your overall health?

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* 11. Please select the top three health challenges you face.

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* 12. Where do you go for routine health care?

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* 13. Where would you go for emergency medical services if you were able to yourself?

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* 14. Are there any issues that prevent you from accessing care? Check all that apply

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* 15. Would you or someone in your household benefit from any of the following Community Services? Check all that apply.

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* 16. What is needed to improve the health of your family and neighbors? Check three

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* 17. What type of health screenings and/or services are needed to keep you and family healthy? (Check up to five).

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* 18. What health issues do you need education about? (Please check up to five)

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* 19. Which of the following preventative procedures have you had in the past 12 months?

0 of 19 answered
 

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