* 2. My zip code is:

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

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

* 5. My main form of transportation is:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* 21. Age

* 22. Gender

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

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

* 25. My Job Status

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

* 27. Highest level of education

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