* 1. From the following list, choose 10 important health and social issues in Bourbon County?

  Options
Aging Issues (e.g.arthritis, Alzheimer’s Disease)
Asthma
Disaster Preparedness
Cancer
Child Abuse
Diabetes
Domestic Violence
Drug and Alcohol Abuse
Fire-arm Related Injuries
Heart Disease & Stroke (high blood pressure, high cholesterol & heart attacks)
Health Insurance (Uninsured)
Health Care Costs (e.g. High co-payments, premiums)
High School Dropouts
HIV/AIDS
Infant Deaths (deaths before one year of age)
Infectious Diseases (e.g. Hepatitis, Tuberculosis)
Low Birth-weight Babies (babies weighing less than 5 pounds when born)
Mental Health (e.g. depression, bipolar, suicide)
Motor Vehicle Accidents
Obesity
Pollution
Poverty
Premature Born Babies (babies born before the 37th week of pregnancy)
Rape/ Sexual Assault
Safe Neighborhoods
Secondhand Smoke
Sexually Transmitted Diseases (e.g. chlamydia, gonorrhea)
Tobacco Use
Teenage Pregnancy (pregnancy in girls 18 and younger)
Unemployment

* 2. Are there any other health and social issues not shown in this list? If you checked "yes", please list the health and social issue below.

* 3. Do you currently have any of the below insurance plans? (Check “yes” or “no” for each type)

  Yes No
Health
Dental
Vision

* 4. In general, would you say your health is:

* 5. What is your sex?

* 6. What is your age?

* 7. Which racial group do you most identify with?

* 8. Do you consider yourself to be Hispanic/Latino?

* 9. Last year what was your total household income from all sources?

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