* 1. Where do you go for routine healthcare?

* 2. Are you able to visit a doctor when needed?

* 3. If you answered "No" to question two, please choose all that apply.

* 4. What type of healthcare coverage do you have?

* 5. What health challenges do you face. (check all that apply)

* 6. What additional health services need to be offered to meet health challenges in your community?

* 7. Please choose all statements below that apply to you.

* 8. What is your age?

* 9. What health screenings or education/information services are needed in your community? (check all that apply)

* 10. What is needed to improve the health of your family and neighbors? (check all that apply)

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