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* 1. Gender:

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* 2. Age Category:

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* 3. Marital Status:

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* 4. How many people live in your household including yourself?

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* 5. Race/Ethnic Origin:

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* 6. Highest level of school you have completed:

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* 7. What is your zip code?

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* 8. Are you the primary care giver for any of the following?

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* 9. Do you:

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* 10. Do you have any of the following in your home?

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* 11. Do you feel safe in your neighborhood?

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* 12. What do you think is healthy about our community?

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* 13. What do you think is unhealthy about our community?

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* 14. In the past 12 months, have you or someone you know had difficulty getting needed healthcare?

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* 15. If you do NOT have health insurance is it because (fill in all that apply):

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* 16. What do you think is the most pressing health care related need for you, your family or our community?

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* 17. In the past 12 months, have you had a(n) (fill in all that apply):

  Yes No I'm Not Sure
General Health exam
Blood pressure check
Cholesterol check
Flu shot
Pneumonia shot
Skin cancer screen
Blood Stool test
Dental exam/teeth cleaned
Breast exam
Mammogram
Diabetes check
Eye exam
Hearing exam
Colon exam
Ultrasound
Stress Test
Biopsy
Surgery

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* 18. Have you been hospitalized in the last:

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* 19. In what ways do you think the hospital is serving the community well?

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* 20. In what ways could the hospital improve the way in which it serves the community?

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* 21. What services do you feel are needed in our community that currently do not exist?

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* 22. Do you see community members working together in collaboration to address community health needs?

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* 23. What is the number one thing the hospital could do to improve the health and quality of life of the community?

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* 24. Any other comments you think are important to address in this survey?

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