Helping women address their social, physical, and mental needs before they get pregnant or in between pregnancies is the best way to increase their overall health.

This survey is to better understand your knowledge, attitudes, and behaviors
regarding health services and support you may receive from social service agencies.

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* 1. County of Residence

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* 2. Zipcode of Residence

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* 3. Age

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* 4. Race(s) (check all that apply)

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* 5. Ethnicity

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* 6. What is the highest degree or level of school you have completed?

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* 7. Household Yearly Income:

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* 8. Employment Status

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* 9. Have you heard of the words "preconception health" or "inter-conception health"?

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* 10. Where do you seek healthcare information or advice? (check all that apply)

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* 11. What barriers do you face when accessing healthcare services? (check all that apply)

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* 12. What barriers do you face when accessing social services to help with housing, food, employment, and everyday needs? (check all that apply)

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* 13. Do you currently have health insurance coverage?

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* 14. Do you have insurance coverage for dental and vision health?

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* 15. What does it mean to you to be "healthy" before you get pregnant?

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* 16. Have you ever been told you have a chronic health condition or illness?

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* 17. If you have a chronic condition or illness, please check all that apply.

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* 18. Are you currently receiving treatment for any chronic health conditions?

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* 19. During the past 30 days, on how many days did you smoke cigarettes or use other tobacco products?

Other tobacco products include cigars, little cigars, cigarillos, e-cigarettes, vapes, vape pens, e-cigars, hookahs, e-hookahs, hookah pens, mods, chewing tobacco, snuff, dip, snus, or dissolvable tobacco products.

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* 20. In the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breath hard some of the time)

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* 21. In the past 7 days, how many times did you eat fruits or vegetables (do not count fruit juice)?

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* 22. Have you seen a doctor or other healthcare provider in the past 12 months for a woman's wellness exam? (not including a visit to the Emergency Department or Urgent Care)

A woman's wellness visit is a yearly exam that includes having a physical or reproductive exam where a doctor or other healthcare provider offers counseling on how to maintain a healthy lifestyle and conducts screenings for health issues.

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* 23. Have you seen a dentist in the past 12 months? (not including a visit to the Emergency Department or Urgent Care)

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* 24. Have you had an eye exam in the past 12 months? (not including a visit to the Emergency Department or Urgent Care)

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* 25. Have you seen a mental health provider in the past 3 months? (not including a visit to the Emergency Department or Urgent Care)

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* 26. How do you get to your doctor appointments? (check all that apply)

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* 27. Have you had a live birth of a child in the past 12 months?

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* 28. What type of birth control method have you used after giving birth or are currently using?

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* 29. In the past 6 months, have you done any of the following because you were unable to afford to do so?

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* 30. In the past 6 months, have you struggled to pay your rent or mortgage?

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* 31. In the past 6 months, have you struggled to buy food or not had enough to eat?

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* 32. Are you making less than $15.00 an hour or $31,200 per year or are making more than this?

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* 33. Do you, or someone in your household, work more than one job to pay your bills?

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* 34. Do you have access to affordable childcare?

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* 35. What do you think can be improved to help women increase their overall health in Butler County?

Thank you for taking the time to share your thoughts with us.

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