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* 2. My zip code is:

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* 3. I think the 3 most important health concerns in our community are: (Check 3 and only 3)

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* 4. I think the 3 main reasons that prevent people from being physically active are: (Check 3 and only 3)

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* 5. I think the 3 main reasons that prevent people from eating healthy foods are: (Check 3 and only 3)

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* 6. I think the 3 most important factors for a healthy community are: (Check 3 and only 3)

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* 7. I would rate the overall health of our community as:

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* 8. During the past 60 days how often did you have a difficult time getting transportation to get to places you wanted or needed to go?

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* 9. During the past 7 days, how many times, on average, did you eat fruit each day?

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* 10. During the past 7 days, how many times, on average, did you eat vegetables each day?

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* 11. During the past 7 days, how many times were you physically active or exercised?

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* 12. During the past 30 days, have you used an electronic cigarette (e-cigarette) or vaped (e.g. Juul or mod)?

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* 13. A doctor, nurse, or other healthcare provider has told me that I have the following condition(s): (Check all that apply)

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* 14. What is your age?

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* 15. What is your gender?

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* 16. What race/ethnic group do you most identify with? (Check only one)

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* 17. Are you Hispanic, Latino, or Spanish origin?

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* 18. What is your current employment status? (Choose only one)

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* 19. What was your total family income last year before taxes? (Choose only one)

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* 20. Do you currently have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare/Medicaid, or Indian Health Service?

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