* 1. How would you rate Comanche County as a healthy county?

* 2. Please rate the safety of Comanche County.

* 3. How would you rate your personal health?

* 4. Where do you usually go when you are sick or need health care? (check all that apply)

* 5. What do you feel are barriers to getting health care in your community? (check all that apply)

* 6. Where do you get information about health resources in Comanche County? (check all that apply)

* 7. Within the past year, what MENTAL health services did you or your family member use in this area? (Check all that apply)

* 8. Within the past year, has any family/friend needed long-term care placement?

* 9. If you needed long-term care placement, was it available in Comanche County?

* 10. How would you rate the following in Comanche County?

  Excellent Good Fair Poor Don't Use
Parks & Recreation
Affordable Housing
Arts & Cultural events
Family Life
Clean Environment
Healthy Behaviors
Shopping
Elder Day Care
Social support for the elderly living at home
Meals on Wheels

* 11. How would you rate the following organizations in Comanche County?

  Excellent Good Fair Poor Don't Use
School System
School Nurses
Hospital
Primary Health Care (includes local doctors, dentists & chiropractors)
Health Department
Mental Health
Police Department
Sheriff Department
Fire Department
EMS/Ambulance Service
Library
UK Extension Service
Road Department
Public Transportation
Childcare Facilities
City/County Government
Senior Citizens

* 12. What do you think are the 5 Most important health problems in Comanche County? (Choose only 5)

* 13. What 3 behaviors have the most negative impact in Comanche County? (check only 3)

* 14. Where are the places you go for recreation in Comanche County? (check all that apply)

* 15. What are the most important Neighborhood issues in Comanche County? (check the top 3)

* 16. Do you have enough money to pay for the following essentials?

  Yes No
Food
Clothing
Housing
Medicine/Healthcare
Childcare

* 17. Think about your monthly income and check the top 5 items you spend your money on first. (check only your top 5)

* 18. Has your health provider ever told you that you have any of the following health problems? (check all that apply)

* 19. Regarding Preventative Health Behaviors, when was the last time you:

  Never Past Year 2-4 Years 5 years or more
Visited a dentist or dental clinic
Had your teeth cleaned
Had an eye exam
Had a flu shot
Had a colorectal cancer screening
Had your cholesterol checked
Had a skin cancer check
Had a blood sugar test (diabetes)
Had a routine check up

* 20. This question is for WOMEN ONLY. When was the last time you:

  Never Past year 2-4 years 5 years or more
Had a mammogram (an x-ray of each breast to look for cancer)
Had a clinical breast exam (health professional feels for lumps)
Had a PAP test (test for cancer of cervix)

* 21. This question is for MEN ONLY. When was the last time you:

  Never Past Year 2-4 Years 5 Years or more
Had a prostate specific antigen test (PSA for prostate cancer)
Had a digital rectal exam

* 22. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities? Such as: self care, work or recreation?

* 23. In the past 30 days, how many days have you felt stressed, depressed or otherwise troubled with emotions that caused you to miss work or recreational activities?

* 24. Do you usually use any device to help you get around such as a cane, wheelchair, crutches or walker?

* 25. How do you rate the following substances in Comanche County?

  A big problem Somewhat of a problem Not a problem
Marijuana
Cocaine
Tobacco
Over the Counter drugs
Prescription Drugs
Alcohol
Methamphetamine

* 26. During an average week, how many alcoholic beverages do you consume?

* 27. Which of the following best describes your tobacco use?

* 28. Do you use any of the following tobacco products? (check all that apply)

* 29. Do you support NO smoking for indoor public buildings in the areas listed?

  Yes No
Your current city of residence
Comanche County as a whole
The state of Texas as a whole

* 30. How many serving of fruit do you eat each day? (serving size is defined as one medium fruit, 3/4 cup of 100% fruit juice, 1/2 cup cooked/canned fruit or 1/2 cup dried fruit)

* 31. How many servings of vegetable do you eat each day? (serving size is defined as one cup of raw, leafy vegetables, 1/2 cup of dried peas or beans, or 3/4 cup 100% vegetable juice)

* 32. How many times a week do you eat at or get take out from restaurants?

* 33. Where do you get your drinking water?

* 34. How many times per week do you participate in moderate physical activities?

* 35. Have you had a sunburn within the past 12 months? Including any time that your skin was red for more than 12+ hours)

* 36. Do you buckle your safety belt when driving or riding in a car?

* 37. Please indicate how often you do the following things:

  Always Sometimes Never N/A
Buckle your child or children aged 3 or younger into a car safety seat while riding in the car
Place a child or children between the ages of 4 - 8 in a booster seat
Place a child or children (up to age 12) buckled only in the backseat when riding in a car
See that your child wears a helmet when riding a bike
See that your child wears a helmet when riding an ATV or motorcycle

* 38. How often do you drive at least 10 mph over the speed limit?

* 39. Have you ever tested your home for Radon? (Radon is a cancer-causing, radioactive, odorless gas that comes from the ground)

* 40. Are you aware that free Radon kits are available at the Health Department for your use?

* 41. Do you have any of the following devices in your home?

  Yes No
Carbon Monoxide detector
Smoke detector
Fire Extinguisher

* 42. Do you think having a hospital in your community is important?

* 43. Do you think having an Ambulance Service is important in the community?

* 44. ** Skip this question if you do not have health insurance (private insurance, medicaid or medicare) ** If you have health insurance, does it cover at least part of the cost for:

  Yes No Don't Know
Dental Services
Vision Services
Mental Health Services
Drug and Alcohol Detox
Prescription Drugs
Chiropractic Care
Family Planning
Immunizations
Smoking Cessation (quit smoking program)
Walking Assistance (crutches, canes, walkers, etc)
Glasses
Hearing Aids

* 45. ** Skip this question if you DO have health insurance (private insurance, medicaid or medicare) ** If you do not have health insurance, what are the reasons? (please check all that apply)

* 46. In the past 12 months, have you been unable to do the following because of cost?

  Never Rarely Often N/A
Go to your healthcare provider
Pay for your medications or treatment
Go to the dentist
Go to a mental health provider
Buy Crutches, walkers, wheelchairs, or other assistive devices
Buy glasses, hearing aids, etc.

* 47. ** Skip this question if you do not have children 18 and younger living in your household ** How many children age 18 and younger in your household have the following types of insurance?

  None One Two Three Four Five or More
Medicaid
Child Health Plan (CHIP or CHP+)
Private either from a parent's employer or purchased directly
No Insurance
Other

* 48. What is your age?

* 49. What is your gender?

* 50. What racial or ethnic group do you identify with?

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

* 52. Which of the following best describes your current relationship status?

* 53. How many people currently live in your household? (including yourself)

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

* 55. How many people living in your household are currently 65 years or older?

* 56. In which type of housing do you currently live?

* 57. What is the highest level of education you have completed?

* 58. What is your approximate average household income?

* 59. Do you or anyone in your household prefer to use a language other than English?

* 60. Do you or anyone in your household receive any of the following? (check all that apply)

* 61. What is your health care coverage? (check all that apply)

* 62. Which of the following categories best describes your employment status?

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