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* 1. What is the zipcode where you live?

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* 2. Please choose an answer for each statement below:

  Strongly Disagree Disagree Agree Strongly Agree
There are adequate sidewalks in Putnam County.
Putnam County has sufficient public transportation.
Putnam County is a safe place to walk and bike.
Putnam County has adequate health and wellness activities.
Putnam County has access to affordable, healthy foods.
Putnam County has adequate and safe access to recreation and exercise.
There are an adequate number of safe places for children to play/exercise in Putnam County.
The public education system in Putnam County adequately meets the health needs of school-age children in the County.
Putnam County is a good place to raise children.
There are support networks for individuals and families in Putnam County.
Neighbors know and trust one another and look out for one another in Putnam County.
Putnam County is a safe place to live.
There are jobs available in Putnam County.
There is sufficient, safe, and affordable housing in Putnam County.
I am satisfied with the quality of life in Putnam County.

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* 3. in your opinion, which three health behaviors or issues do people in Putnam County need more information about? 

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* 4. Please look at the list of community issues below. In your opinion, which three issues most affect quality of life in Putnam County?

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* 5. Would you say that, in general, your health is

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* 6. Have you ever been told by a doctor, nurse or other health professional that you have any of the health conditions below:

  Yes No Don't Know Rather Not Asnwer
Asthma
Cancer
Dementia or Alzheimer's
Depression or Anxiety 
Diabetes (high blood sugars) 
Heart Disease 
High Blood Pressure
High Cholesterol
Osteoporosis 
Overweight or Obesity

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* 7. Once you were told of the above 1 or more diagnoses have you followed up?

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* 8. Where do you go for exercise or physical activity?

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* 9. In the past 12 months did you have a problem getting health care you needed for yourself or a family member?

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* 10. If you said "yes" to the question above, what type of health care did you have difficulty getting?

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* 11. Which of the problems below have prevented you from getting health care in the past year?

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* 12. What is your gender?

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* 13. What is your race? (Please check all that apply).

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* 14. What is your marital status?

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* 15. What is your age range?

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

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* 17. What is your approximate household income?

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* 18. What is your current employment status?

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* 19. How many people does your income support?

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* 20. Do you care for an elderly adult in your household?

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* 21. Do you have personal access to the Internet at home?

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