The Lawrence County Health Department is located in Ironton, Ohio and is committed to monitoring community health status, identifying and addressing public health threats, enforcing laws that protect the public’s health, and providing services to prevent and control diseases for the residents of Lawrence County. We are reaching out to community residents to gather input by conducting a community survey. Survey information will be used by the Lawrence County Health Department to identify unmet health needs to develop a plan for creating a program to address and prevent obesity. The survey includes 30 questions and should take less than 10 minutes to complete. If there are questions you prefer not to answer, you may skip those questions and submit the survey with unanswered questions. Your responses are anonymous and will remain confidential. We would like to thank the Pallottine Foundation of Huntington for funding this health initiative.

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* 4. What is your age?

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* 5. What is your gender?

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* 6. What race or ethnicity best represents you?

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* 7. What is your primary language?

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* 8. What is your employment status?

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* 9. What is your annual household income?

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

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* 11. How many people live in your household?

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* 12. Do you consider yourself?

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* 13. Do you use any tobacco products? (Check all that apply.)

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* 14. Do you have a personal or family history of the following? (Check all that apply.)

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* 15. Do you want to get in better shape?

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* 16. Are you currently doing anything to improve your health or lose weight? (Check all that apply)

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* 17. If you do want to get healthier and in better shape, what, if anything, do you feel is holding you back? (Check all that apply)

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* 18. Would you consider any of the following people in your life overweight or obese? (Check all that apply)

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* 19. If your family members are overweight, how does that make you feel?

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* 20. For lunch at school or work, you usually:

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* 21. How many days a week do you cook dinner (your main meal) at home?

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* 22. How often do you eat fast food (e.g., McDonald’s, pizza, KFC, Taco Bell, Wendy’s, quick neighborhood takeout, etc.)?

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* 23. On average, how often do you eat out?

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* 24. If you eat out, what influences your decision to eat out most?

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* 25. How often do you drink the following: regular soda, sweetened coffee drinks, milkshakes, energy drinks, etc.?

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* 26. How often do you usually eat fruit? (Include fresh, frozen, dried, or canned. Do not include juice.)

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* 27. How often do you usually eat vegetables? (Include fresh, frozen, or canned. Do not count French fries, potato chips, or rice.)

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* 28. Which of these statements best describes the food eaten in your household in the last 12 months:

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* 29. In the past week, how many days did you exercise for at least 30 minutes? (This includes activities like fitness or dance classes, playing soccer, walking, or jogging. The 30 minutes could be all at one time or a few minutes at a time.)

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* 30. In the past week, how many days did you do exercise to strengthen your muscles? (This includes activities like yoga, lifting weights, doing pushups, situps, or planks.)

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* 31. Do you have any physical disabilities or long-term health problems? (Long term means 6 months or more.)

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* 32. What keeps you from being physically active? (Check all that apply)

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* 33. If you have health improvement or obesity prevention goals in mind, what types of programming would you like to see the Lawrence County Health Department offer? (Check all that apply.)

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* 34. Where did you hear about this survey? (Check all that apply.)

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