* 1. sex:

* 2. How old are you?

* 3. Race (mark all that apply)

* 4. What is the highest level of education that you completed?

* 5. How many people does your income support?

* 6. How many people live in your home?

* 7. What is your marital status?

* 8. What is your employment status?

* 9. What zip code do you currently reside in?

* 10. As a Davie County citizen, what is the biggest challenge you and your family members face?

* 11. Where do you get most of your health-related information?

* 12. The recommendation for physical activity is 30 minutes a day, 5 days a week or 2.5 hours a week.  Pick the main reason that keeps you from getting this much physical activity.

* 13. In your opinion, which of the health behaviors do people in your own community need more information about?

* 14. It is recommended for individuals to eat at least 5 servings of fruit and vegetables a day (this does not include French fries or potato chips).  Pick the main reason that keeps you from meeting this goal.

* 15. Are you and your family up-to-date on your vaccinations (required shots)?

* 16. If you or your family are not up-to-date on your vaccinations (required shots), what is the main reason?

* 17. Which of these recommended health screenings have you had in the last year?

* 18. Where do you usually go for healthcare when you are sick? (choose one)

* 19. Do you or anyone in your household have any of the chronic conditions listed below?

* 20. If you identified conditions in question 19, are you being monitored or receiving treatment for those conditions?

* 21. Have you or a family member had difficulties getting services for mental or behavioral health in Davie County?

* 22. If a friend or family member needed help and/or counseling for suicide prevention who would you tell them to contact?

* 23. In your opinion, what is the biggest substance abuse problem in this county?

* 24. Do you currently use tobacco products? (this includes cigarettes, chew, dip, snuff)

* 25. Do you currently use vaping products (e-cigs, vape pen, vape mod, etc)

* 26. If you currently use tobacco or vaping products, where would you go for help if you wanted to quit?

* 27. Do you use any of the following safety measures in your home?

* 28. We are interested in helping young children be ready for school.  To help us help your child, please tell us what you would like to learn more about.

* 29. During the past week, how many days did you or another family member read to your child (age 0-6 years old)

* 30. If you have children and can't find adequate child care; what is the main reason?

* 31. How would you prefer to receive county-wide urgent information (choose one)

* 32. In the event of a public health emergency (i.e. Anthrax attack) what do you see as a limitation?

* 33. Do you have an emergency survival kit (water, flashlight, batteries, etc.) in your home?

* 34. Do you have any suggestions or recommendations that the Davie County Health Department could do to make our community a better place?

* 35. Do you have a family member that is being taken care of at home due to physical or mental limitations?

* 36. If you have a family member that's being taken care of at home; are you paying for those services?

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