Please answer each question to the best of your ability, based on your personal experience.

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* 1. How would you rate your county as a “healthy community?"

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* 2. In your opinion, what are the THREE most significant health problems in your county? (Problems that have the greatest impact on overall community health)

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* 3. In your opinion, what are the THREE most significant health behaviors in your county? (Behaviors that have the greatest impact on overall community health)

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* 4. How would you rate your individual health?

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* 5. Please select the top THREE health challenges you currently face.

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* 6. During the past 30 days, how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

0 days 15 days 30 days
i We adjusted the number you entered based on the slider’s scale.

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* 7. In regards to your physical health, including physical illness and injury, how many days during the past 30 days was your physical health NOT good?

0 days 15 days 30 days
i We adjusted the number you entered based on the slider’s scale.

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* 8. In regards to your mental health, including stress, depression, and problems with emotions, how many days during the past 30 days was your mental health NOT good?

0 days 15 days 30 days
i We adjusted the number you entered based on the slider’s scale.

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* 9. During the past 12 months, what has been the biggest source of stress in your life?

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* 10. In the past 12 months, did you receive counseling or treatment for mental health concerns?

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* 11. If you felt you needed mental health treatment or counseling but did not receive it, what was the primary obstacle preventing you from receiving care?

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* 12. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.

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* 13. How many of your permanent teeth have been removed because of tooth decay or gum disease? (This includes teeth lost to infection, but not teeth lost for other reasons, such as injury or orthodontics. )

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* 14. During the past 12 months, how often did you have to cut meal sizes or skip meals due to insufficient money for food?

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* 15. Do you currently have any kind of healthcare coverage, including health insurance, prepaid plans (HMOs),  government plans (Medicaid/Medicare), or Indian Health Services?

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* 16. Of the following support services, which one do YOU most need, that you are not currently getting?

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* 17. During the past 30 days, have you participated in any physical activities or exercise such as running, biking, calisthenics, or walking for exercise?

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* 18. If there was a time in the past 12 months when you needed to see a doctor but could not, what obstacles prevented you from receiving care? Select all that apply.

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* 19. How often do you currently use tobacco products, such as chewing tobacco, cigarettes, snuff, or snus?

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* 20. How often do you currently use e-cigarettes or other electronic “vaping” products?

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* 21. During the past 30 days, how many days did you have at least one alcoholic beverage such as beer, wine, a malt beverage, or liquor?

0 days 15 days 30 days
i We adjusted the number you entered based on the slider’s scale.

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* 22. In the past seven days, how many days did you exercise for at least 30 minutes?

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* 23. During the past 30 days, how many times per day and per week did you eat fruit? Count fresh, frozen or canned fruit, NOT juice.

  0 1-2 3-4 5+ Unknown/ Not sure
Times per day
Times per week

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* 24. If you did not eat fruit in the past 30 days, please explain why.  If you did, please skip to the next question.

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* 25. During the past 30 days, how many times per day, and per week, did you eat green vegetables such as broccoli romaine, chard, collard greens or spinach?

  0 1-2 3-4 5+ Unknown/ Not sure
Times per day
Times per week

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* 26. If you did not eat greens in the past 30 days, please explain why.  If you did, please skip to the next question.

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* 27. In the past 12 months, how often did alcohol use, by you or another member of your household, cause stress, conflict, or anxiety for you?

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* 28. Do you currently have enough non-perishable food, water, medical supplies and other supplies (e.g. flashlights, radio, batteries, etc.) at your home to be able to stay in place during an emergency or disaster for up to 3 days?

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* 29. Do you have an established emergency or disaster plan (Actions you would take, including how you would communicate with family or friends during an emergency) for you and your family?


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* 30. What is your home zip code?

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* 31. Indicate your gender.

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* 32. Indicate your race/ethnicity.

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* 33. Select the category that includes your age.

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* 34. What is your marital status?

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* 35. What is your highest level of education?

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* 36. In 2016, what was your annual household income from all sources?

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* 37. How many children live in your household? If none, write 0.

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* 38. Would you like to provide us with your name and contact information to be entered into a drawing for a Kindle Fire?

***Your survey answers are not part of a HIPAA protected medical record, however your contact information will be kept confidential.***

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* 39. THIS IS VOLUNTARY. Your survey answers are not part of a HIPAA protected medical record, however any and all contact information will be kept confidential.

 

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