How old are you?

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* 1. How old are you?

What is your gender?

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* 2. What is your gender?

Which of the following best describes your current relationship status?

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* 3. Which of the following best describes your current relationship status?

What is the highest level of education you have completed?

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* 4. What is the highest level of education you have completed?

Which of the following categories best describes your employment status?

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* 5. Which of the following categories best describes your employment status?

In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 6. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

In your home, do you: 

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* 7. In your home, do you: 

If you have children or other dependents in your care, what is your family situation? (check all that apply)

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* 8. If you have children or other dependents in your care, what is your family situation? (check all that apply)

Which of the following is your MAIN source of health insurance coverage?

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* 9. Which of the following is your MAIN source of health insurance coverage?

Does a disability, handicap or chronic disease keep you and/or your spouse/partner from fully participating in work, school, housework, or other life activities?

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* 10. Does a disability, handicap or chronic disease keep you and/or your spouse/partner from fully participating in work, school, housework, or other life activities?

Outside of routine health care appointments, please share your personal situation over the last 12 months. (check all that apply)

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* 11. Outside of routine health care appointments, please share your personal situation over the last 12 months. (check all that apply)

  I have experienced a need. I have received help.
Dental care
Mental health care
Parenting support
Pediatric services
Health care for seniors
Aging in a safe and supportive environment
Elder abuse
Adequate, affordable health insurance
Disability counseling
Affordable prescription drugs
Alcohol, drug or pain medication misuse
Need for recreational opportunities and active living
Poor nutrition/unhealthy food habits
Income, poverty and family stress
Access to healthy food
If you were unable to receive assistance for any issue identified in the previous question, what barrier(s) prevented you? (check all that apply)

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* 12. If you were unable to receive assistance for any issue identified in the previous question, what barrier(s) prevented you? (check all that apply)

Please choose all statements that apply to you:

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* 13. Please choose all statements that apply to you:

  Yes No Sometimes
I exercise at least 3 times per week
I smoke tobacco products (cigars, cigarettes, etc)
I eat at least 5 servings of fruits and vegetables each day
I chew tobacco
I receive a flu shot each year
I use e-cigarettes and/or vape instead of tobacco products
I eat fast food more than 1 time per week
I use sunscreen or protective clothing for planned time in the sun
I use illegal drugs
I have access to a wellness program through my employer
I overuse prescription drugs
I drink more than 3 alcoholic drinks per day
I have skipped taking my prescribed medications, or delayed getting prescriptions filled, due to the expense. 
Which of the following preventive procedures have you had in the past 12 months? (check all that apply)

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* 14. Which of the following preventive procedures have you had in the past 12 months? (check all that apply)

What services or resources do YOU lack to be as healthy as possible? (check all that apply)

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* 15. What services or resources do YOU lack to be as healthy as possible? (check all that apply)

What health screenings, education, information or services are lacking in your COMMUNITY? (choose all that apply)

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* 16. What health screenings, education, information or services are lacking in your COMMUNITY? (choose all that apply)

As you age, how important is it for you to remain in your COMMUNITY (where your current home is located)?

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* 17. As you age, how important is it for you to remain in your COMMUNITY (where your current home is located)?

How important is it for you to remain in your own HOME as you age?

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* 18. How important is it for you to remain in your own HOME as you age?

What are (or anticipated to be) the biggest barriers to aging safely in your own home? (choose all that apply)

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* 19. What are (or anticipated to be) the biggest barriers to aging safely in your own home? (choose all that apply)

How frequently do you interact (by phone or in person) with your friends, family or neighbors in your community?

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* 20. How frequently do you interact (by phone or in person) with your friends, family or neighbors in your community?

When considering your support system to rely upon in times of need, you would: (check all that apply)

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* 21. When considering your support system to rely upon in times of need, you would: (check all that apply)

A routine check up is a general physical exam, not an exam for a specific injury, illness or condition. About how long has it been since you last received:

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* 22. A routine check up is a general physical exam, not an exam for a specific injury, illness or condition. About how long has it been since you last received:

  Less than a year ago 1-2 years ago 3-4 years ago 5 or more years ago Unsure Never
A Routine Check Up
A Dental Check Up
An Eye Exam
In the past 3 years, has a doctor, nurse or other health care provider diagnosed and treated you for: (check all that apply)

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* 23. In the past 3 years, has a doctor, nurse or other health care provider diagnosed and treated you for: (check all that apply)

  I have been diagnosed. The condition is managed through exercise/lifestyle changes. I am currently taking prescribed medications for the condition.  I have not sought medical treatment.
High Blood Pressure
High Cholesterol
Heart condition or Heart Disease
Mental Health condition, such as anxiety, OCD, PTSD, or depression?
Diabetes, either Pre-, Type 1 or Type 2
Asthma
Chronic Pain
Please check the TOP 3 primary sources you access for health information or clarification on health related issues?

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* 24. Please check the TOP 3 primary sources you access for health information or clarification on health related issues?

Does the community where you live have the following: (check all that apply)

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* 25. Does the community where you live have the following: (check all that apply)

Where would you access information if you, a family member or friend were seeking services for older adults, such as home delivered meals, home repair, medical transporting, caregiver services or social activities? (check all that apply)

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* 26. Where would you access information if you, a family member or friend were seeking services for older adults, such as home delivered meals, home repair, medical transporting, caregiver services or social activities? (check all that apply)

Are you currently the primary caregiver for a loved one (someone who cannot fully care for themselves)?

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* 27. Are you currently the primary caregiver for a loved one (someone who cannot fully care for themselves)?

Do you anticipate being a primary caregiver in the near future?

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* 28. Do you anticipate being a primary caregiver in the near future?

If you are a primary caregiver for a loved one, do you reside with the person you are caring for?

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* 29. If you are a primary caregiver for a loved one, do you reside with the person you are caring for?

If you are a primary caregiver for a loved one, what are your concerns about doing that successfully? (check all that apply)

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* 30. If you are a primary caregiver for a loved one, what are your concerns about doing that successfully? (check all that apply)

If you could change one thing that you believe would contribute to better health in your COMMUNITY, what would you change?

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* 31. If you could change one thing that you believe would contribute to better health in your COMMUNITY, what would you change?

If you could change one thing that you believe would contribute to better health FOR YOU, what would that change be?

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* 32. If you could change one thing that you believe would contribute to better health FOR YOU, what would that change be?

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