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* 1. What is your zip code?

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* 2. What is your gender?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. How many people currently live in your household?

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* 6. How long have you lived in the area?

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* 7. During the past 12 months have you received a flu shot?

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* 8. Have you ever been told by a doctor you have high blood pressure?

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* 9. If yes, is any medication currently prescribed for your  high blood pressure?

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* 10. Have you ever been told by a doctor you need to lose weight for health reasons?

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* 11. During the past month have you participated in any physical activities or regular exercise, such as running, walking, golf, etc?

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* 12. How many times a week do you participate in this activity?

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* 13. How many minutes or hours do you usually keep at this activity?

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* 14. Are you currently trying to lose weight?

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* 15. If yes, how are trying to lose weight?

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* 16. Do you currently smoke?

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* 17. Do you use smokeless tobacco?

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* 18. Have YOU ever been told by a doctor that you have one of the following conditions?

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* 19. Do have a Family History of one of the following conditions?

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* 20. Has a child (age 17 or younger) in your household been diagnosed with one of the following conditions?

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* 21. If a child in your household has asthma, how many times during the past year did you visit the Emergency Room because of asthma?

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* 22. Has a child (age 17 or younger) in your household used the following:  (check all that apply)

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* 23. Has a child (age 17 or younger) in your household become pregnant?

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* 24. Are you or any household member a primary caregiver for an aged, disabled or chronically ill person?

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* 25. How long has it been since you visited the doctor for a routine preventative check? ( Not for specific injury, illness or condition).

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* 26. If your last visit was more than two years ago, is it because -

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* 28. How many times during the last 12 months have you or any household member used a hospital emergency room?

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* 29. If you or a household member used a hospital emergency room in the past 12 months, was it due to:

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* 30. How many times in the last 12 months have you or any household member used an Urgent Care, Rural Health Clinic or Federally Qualified Health Clinic - Check all that apply

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* 31. Have you or anyone in your household had any difficulty finding a doctor within the past two years?

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* 32. If you had trouble finding a doctor, why?  (Please check all that apply)

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* 33. Have you or anyone in your household had difficulty finding a doctor to treat a specific illness or condition in your area within the past two years?

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* 34. If yes, what type of specialist were you looking for?

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* 35. Why were you unable to visit the specialist when you needed one?

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* 36. How long has it been since you had your blood cholesterol level checked?

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* 37. Have you ever been told by a doctor or health care professional that your blood cholesterol is too high?

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* 38. How long has it been since you had your blood checked for diabetes?

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* 39. Have you ever been told by doctor or health care professional you have high  blood sugar or diabetes?

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* 40. If you are over 50 years old, how long has is been since you had an exam or screening for colon cancer?

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* 41. If you are over 40 years old, how long has is been since your last mammogram?

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* 42. If you are over 25 years old, how long has is been since your last Pap smear?

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* 43. Have you  or any household member required skilled nursing care in hospital or nursing home in the last 12 months?

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* 44. Do you anticipate you or any household member needing skilled nursing care in hospital or nursing home in the next two years?

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* 45. Have your used a virtual visit to talk to a provider over the computer or mobile device?

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* 46. Do you access your health records through an online patient portal?

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* 47. What do you think are the most pressing health problems in your community?

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* 48. What medical services are most needed in your community?  ( Check all that apply)

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* 49. What types of health education services are most needed in your community? (Check all that apply)

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* 50. What health or community services should be provided that are currently not available?

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* 51. What ideas or suggestions do you have for improving the overall health of the area community?

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* 52. What is the highest level of school you have completed or the highest degree you have received?

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* 53. Including yourself, how many adults in your household are retired?

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* 54. Including yourself, how many adults ( ages 18 and over) in your household are employed fulltime?

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* 55. How many household members are currently covered by health insurance?

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* 56. If you or members of your household have health insurance coverage, how is it obtained? (check all that apply)

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* 57. Do you have a Medicare Advantage Plan?

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* 58. Do any of your insurance policies provide dental coverage?

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* 59. Do any of your insurance policies pay for prescription drugs?

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* 60. Are medical, dental or prescription co-pays large enough that you postpone or go without services or prescriptions?

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* 61. Do you have long term care (nursing home) insurance?

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* 62. Do you have a durable power of attorney in place?

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* 63. Do you have trouble getting transportation to health care services?

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* 65. Counting all income sources from everyone in your household, what was the combined household income last year? (Optional)

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* 66. How would you describe your housing situation?

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* 68. To be included in a drawing for one of five $100 gift cards, please complete the following information:

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