* 1. Do you live in Raleigh County?

* 2. How old are you?

* 3. What is your gender?

* 4. What is your marital status?

* 5. What is your highest level of education?

* 6. How many people live in your home?

* 7. Do you have children under age 18 living in your home?

* 8. Do you have children over age 18 living in your home?

* 9. Do you take medications?

* 10. How would you rate your overall health?

* 11. Of the activities listed below, what are you doing that could be harming your safety?

* 12. Of the activities listed below, what are you doing that could be harming your health?

* 13. Of the activities listed below, what are you doing that could be improving your health?

* 14. Is there someone in your household addicted to drugs?

* 15. Do you use tobacco products?

* 16. What type of tobacco products do you use? (Check all that apply, or check "N/A")

* 17. Do you drink alcohol?

* 18. On average. how many drinks do you have per week? (NOTE: a drink is defined as one beer, one glass of wine or one shot of whiskey)

* 19. What do you think is the greatest health need in Raleigh County?

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