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* 1. How old are you?

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* 2. Sex?

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* 3. Do you live in the network's service area of Gogebic, Iron, or Vilas County?

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* 4. How long have you lived in Northern Wisconsin or Upper Michigan?

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* 5. What is your employment status?

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* 6. Are you a Veteran?

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* 7. Do you currently have a primary care provider?

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* 8. What city or community do you most often use for medical and dental care?

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* 9. Do you have health insurance?

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* 10. If Yes, do you receive:

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* 11. Do you have dental insurance?

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* 12. Have you had a physical or routine check-up in the 12 months?

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* 13. Have you received any dental care in the past 12 months?

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* 14. In the last 12 months have you postponed or avoided receiving medical or dental care because of cost concerns?

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* 15. Have you been screened for cancer, heart disease, or diabetes in the past 12 months?

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* 16. How would you rate your access to the following services?

Hospitals and Emergency Rooms?

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* 17. Outpatient Medical Clinics, including Urgent Care Centers?

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* 18. Behavioral Health Services, including Substance Abuse Treatment?

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* 19. Dental Care?

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* 20. Please rank from the list below your top five (5) rural health needs, with #1 being your most important concern and #5 being the lowest:

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