* 1. How old are you?

* 2. What is your gender?

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

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

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

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

* 7. In your home, do you: 

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

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

* 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?

* 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

* 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)

* 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. 

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

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

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

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

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

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

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

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

* 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

* 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

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

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

* 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)

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

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

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

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

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

* 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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