This survey will take less than five minutes. Thank you for helping us find ways to create a healthier community.
 
This survey is being conducted by HSHS Holy Family Hospital, HSHS St. Joseph’s Hospital in Breese, and HSHS St. Joseph’s Hospital in Highland.

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* 1. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 2. What is your gender?

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

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* 4. What is your approximate average household income?

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* 5. Select the option(s) that best describe your race/ethnicity:

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* 6. What is your zip code?

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* 7. What is your disability status?

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* 8. Rank the following health concerns in order from 1 (most important health concern) to 6 (least important health concern) by dragging your choices up or down.

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* 9. How would you rate YOUR overall health?

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* 10. How would you rate the health of Bond County?

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* 11. How would you rate the health of Clinton County?

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* 12. How would you rate the health of Madison County?

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* 13. What do you think is/are the biggest health problems facing Bond, Clinton, and Madison counties?

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* 14. What is the one thing you would do to make the health of Bond, Clinton, and Madison counties better?

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