Question Title

* 1. Are you male or female?

Question Title

* 2. What is your age?

Question Title

* 3. Which of the following best describes your current relationship status?

Question Title

* 4. How many people currently live in your household?

Question Title

* 5. Do you have any children under 18?

Question Title

* 6. What is your ethnicity? (Please select all that apply.)

Question Title

* 7. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

Question Title

* 8. How much total combined money did all members of your HOUSEHOLD earn last year?

Question Title

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

Question Title

* 10. Which of the following categories best describes your employment status?

Question Title

* 11. Which of the following best describes your current occupation?

Question Title

* 12. In a typical week, how many days do you exercise?

Question Title

* 13. In general, how would you rate your overall health?

Question Title

* 14. What are your personal health concerns? (Check all that apply)

Question Title

* 15. What is the need, in your community, for ACCESS TO HEALTHCARE? (Medical Professional Shortage)

Question Title

* 16. What is the need, in your community, for ADDICTION/SUBSTANCE ABUSE TREATMENT?

Question Title

* 17. What is the need, in your community, for AFFORDABLE HEALTH INSURANCE? 

Question Title

* 18. What is the need, in your community, for CANCER TREATMENT?

Question Title

* 19. What is the need, in your community, for DENTAL OR ORAL HEALTH? 

Question Title

* 20. What is the need, in your community, for DIABETES TREATMENT OR EDUCATION?

Question Title

* 21. What is the need,  in your community, for HEART DISEASE/STROKE TREATMENT OR EDUCATION?

Question Title

* 22. What is the need, in your community, for HIV/AIDS TREATMENT?

Question Title

* 23. What is the need, in your community, for HOME HEALTH SERVICES AND EQUIPMENT?

Question Title

* 24. What is the need, in your community, for MATERNAL/CHILD HEALTHCARE?

Question Title

* 25. What is the need, in your community, for MENTAL HEALTH SERVICES? 

Question Title

* 26. What is the need, in your community, for AFFORDABLE PRESCRIPTION DRUGS?

Question Title

* 27. What is the need, in your community, for RELIABLE HEALTH INFORMATION/EDUCATION?

Question Title

* 28. What is the need, in your community, for SEXUALLY TRANSMITTED DISEASE TREATMENT OR EDUCATION?

Question Title

* 29. What is the need, in your community, for SLEEP DISORDER TREATMENT?

Question Title

* 30. What is the need, in your community, for TOBACCO CESSATION HELP?

Question Title

* 31. What is the need, in your community, for TEEN PREGNANCY EDUCATION 

Question Title

* 32. What is the need, in your community, for TRANSPORTATION FOR MEDICAL NEEDS? 

Question Title

* 33. What is the need, in your community, for WEIGHT CONTROL (obesity treatment)?

Question Title

* 34. What level of impact does AFFORDABLE HOUSING have on the health of your community?

Question Title

* 35. What level of impact does AFFORDABLE CHILD CARE have on the health of your community?

Question Title

* 36. What level of impact does ALCOHOL AND DRUG USE have on your Community?

Question Title

* 37. What level of impact does CHILD ABUSE have on the health of  your community?

Question Title

* 38. What level of impact does CRIME (police and fire protection) have on  the health of your community?

Question Title

* 39. What level of impact does DISABILITIES have on the health of your community?

Question Title

* 40. What level of impact does ELDERLY CARE have on the health of your community?

Question Title

* 41. What level of impact does MALNUTRITION have on the health of your community?

Question Title

* 42. What level of  impact does THE LACK OF EDUCATION/LOW GRADUATION RATES have on the health of your community?

Question Title

* 43. What level of impact does LACK OF PLACES TO EXERCISE (parks) have on the health of your community?

Question Title

* 44. What level of impact does JUVENILE DELINQUENCY have on the health of your community?

Question Title

* 45. What level of impact does POVERTY have on the health of your community?

Question Title

* 46. What level of impact does SHORTAGE OF CHARITY PROGRAMS have on the health of your community?

Question Title

* 47. What level of impact does UNEMPLOYMENT have on the health of your community?

Question Title

* 48. What level of impact does the LACK OF TRANSPORTATION have on the health of your community?

Question Title

* 49. How would you like to receive FREE health education/information?

T