Community Hospital-Fairfax Community Health Needs Assessment

1. About You

Question Title

* 1. In what zip code is your home located?

64446

64491

64482

64496

64498

64473

64437

64470

64487

64451

64446

64428

Other (please specify)

Question Title

* 2. What is your gender?

Female

Male

Question Title

* 3. What are the ages of the people who live in your household?

	0-2	3-18	19-44	45-64	65 plus
Yourself	Yourself 0-2	Yourself 3-18	Yourself 19-44	Yourself 45-64	Yourself 65 plus
Person 2	Person 2 0-2	Person 2 3-18	Person 2 19-44	Person 2 45-64	Person 2 65 plus
Person 3	Person 3 0-2	Person 3 3-18	Person 3 19-44	Person 3 45-64	Person 3 65 plus
Person 4	Person 4 0-2	Person 4 3-18	Person 4 19-44	Person 4 45-64	Person 4 65 plus
Person 5	Person 5 0-2	Person 5 3-18	Person 5 19-44	Person 5 45-64	Person 5 65 plus
Person 6	Person 6 0-2	Person 6 3-18	Person 6 19-44	Person 6 45-64	Person 6 65 plus