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* 1. In what ZIP code is your home located?

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* 2. What do you think are the most pressing health problems in your community? (check all that apply)

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* 3. What medical services are most needed in your community? (check all that apply)

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* 4. Please check the types of health education services most needed in your community. (check all that apply)

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* 5. Including yourself, how many people in your household are in fair-to-poor health?

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* 6. How long has it been since you last visited a doctor for a routine check-up? A routine check-up is a general visit, not a visit for a specific injury, illness or condition.

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* 7. If your last visit was more than two years ago, is it because you--

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* 8. If you or a household member have a health care need, do you have a doctor you can go to?

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* 9. If you or a household member have a health care need, do you have a dentist you can go to?

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* 10. If you or a household member have a health care need, do you have a mental health specialist you can go to?

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* 11. If you or a household member have a health care need, do you have a substance abuse counselor you can go to?

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* 12. How many times during the past 12 months have you or any household member used a hospital emergency room?

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* 13. If you or a household member used a hospital emergency room in the past 12 months, was it due to an injury that required immediate attention?

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* 14. Have you or anyone in your household had any difficulty finding a doctor within the past two years?

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* 15. If yes, why did you have trouble finding a doctor?

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* 16. Have you or anyone in your household had any difficulty finding a doctor that treats specific illnesses or conditions in your area within the past 2 years?

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* 17. If yes, what kind of specialist did you look for?

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* 18. How many household members are currently covered by health insurance?

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* 19. If you or members of your household have health insurance coverage, how is it obtained? (check all that apply)

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* 20. Do any of these insurance policies provide dental coverage?

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* 21. Do any of these insurances pay for prescription drugs?

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* 22. Are medical, dental or prescription co-pays a large enough problem that you postpone or go without services or prescriptions>

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* 23. Where is your primary care physician located?

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* 24. Do you have trouble getting transportation to health care services?

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* 25. How many miles do you travel to see a doctor, one way:

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* 26. How many miles do you travel to a hospital, one way?

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* 27. How many miles do you travel to school or job training, one way?

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* 28. How many miles do you travel for child care, one way?

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* 29. How many miles do you travel to your job, one way?

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* 30. If medical transportation was more readily available, would you schedule a ride to your doctor, pharmacy, etc.?

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* 31. During the past 12 months, have you received a flu shot?

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* 32. Have you ever been told by a doctor you should lose weight for health reasons?

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* 33. During the past month have you participated in any physical activities or exercise, such as running, walking, golf, etc.?

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* 34. If yes, how many times a week do you take part in this activity?

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* 35. Do you smoke?

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* 36. If yes, how many cigarettes do you smoke on an average day?

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* 37. Have you ever been told by a doctor that you have one of the following conditions? (check all that apply)

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* 38. Has a child in your household (age 17 or younger) been told by a doctor that they have one of the following conditions? (check all that apply)

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* 39. If a child in your household has asthma, how many times during the past 12 months did you visit an emergency room because of asthma?

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* 40. What health or community service(s) should be provided that are currently not available?

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