My zip code is:

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* 2. My zip code is:

I have this type of health care coverage:

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* 3. I have this type of health care coverage:

A doctor, nurse, or healthcare provider, told me that I have the following: (Check all that apply.)

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* 4. A doctor, nurse, or healthcare provider, told me that I have the following: (Check all that apply.)

My main form of transportation is:

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* 5. My main form of transportation is:

I think these are 3 main reasons why people in our community do not seek health care:

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* 6. I think these are 3 main reasons why people in our community do not seek health care:

I think these are 3 main reasons that prevent people from being physically active in our community:

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* 7. I think these are 3 main reasons that prevent people from being physically active in our community:

I think these are 3 main reasons that prevent people in our community from eating healthy foods:

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* 8. I think these are 3 main reasons that prevent people in our community from eating healthy foods:

I think these are the 3 most important health concerns on our community:

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* 9. I think these are the 3 most important health concerns on our community:

I think these are the 3 most important factors for a healthy community:

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* 10. I think these are the 3 most important factors for a healthy community:

I would rate the overall health of our community as:

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* 11. I would rate the overall health of our community as:

I use the following tobacco products (check all that apply).

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* 12. I use the following tobacco products (check all that apply).

I agree with the idea of smoke free workplaces, including restaurants and bars.

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* 13. I agree with the idea of smoke free workplaces, including restaurants and bars.

I am exposed to secondhand smoke. (i.e. smoke from someone else who may be smoking in my home, workplace, or public place.)

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* 14. I am exposed to secondhand smoke. (i.e. smoke from someone else who may be smoking in my home, workplace, or public place.)

If you are exposed to second hand smoke, where (check all that apply)

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* 15. If you are exposed to second hand smoke, where (check all that apply)

In the last 2 days, how many fruits and vegetables have you eaten?

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* 16. In the last 2 days, how many fruits and vegetables have you eaten?

In the last week, how many times were you physically active or exercised?

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* 17. In the last week, how many times were you physically active or exercised?

How important is it to be physically active or exercise?

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* 18. How important is it to be physically active or exercise?

How important is it to eat fruits and vegetables?

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* 19. How important is it to eat fruits and vegetables?

In the last 30 days when I bought fruits and vegetables, they were (check all that apply)

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* 20. In the last 30 days when I bought fruits and vegetables, they were (check all that apply)

Age

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* 21. Age

Gender

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* 22. Gender

Which race/ethnic group do you most identify with? (Choose only one)

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* 23. Which race/ethnic group do you most identify with? (Choose only one)

Are you of Hispanic, Latino or Spanish origin?

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* 24. Are you of Hispanic, Latino or Spanish origin?

My Job Status

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* 25. My Job Status

My household income (in $) is:

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* 26. My household income (in $) is:

Highest level of education

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* 27. Highest level of education

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