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* 1. Do you have any of the following health risks? (Please select all that apply.)

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* 2. If you have any of the above conditions, how do you manage?

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* 3. What resources do you need to better manage your health risk?

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* 4. What is your main environmental safety concern?

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* 5. Do you know the Northern Panhandle has elevated levels of Radon found in homes?

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* 6. Are you aware Lyme Disease has significantly increased in our area in the last three years?

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* 7. After being outdoors, do you check yourself and/or family members for ticks?

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* 8. Do you use any of the following tobacco products?

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* 9. If so, during the past 12 months have tried to quit?

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* 10. Would a cell phone based cessation program be helpful to quit?

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* 11. Do you or a family member suffer from any of the following addictions? (Please select all that apply.)

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* 12. Do you feel there are adequate treatment programs for the conditions listed in question 11?

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* 13. Do you know there are needle exchange programs in our area?

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* 14. How often do you exercise?

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* 15. Do you pay attention to making healthy food choices?

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* 16. What are the leading reasons you limit fruit and vegetable intake?

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* 17. If you want to live a healthy lifestyle, what do you need improvements and/or education on? (Please select all that apply.)

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* 18. Which, if any, service does your family need? (Please select all that apply.)

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* 19. Are you Male or Female?

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

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* 21. How old are you?

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* 22. What is your marital status?

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* 23. How many people are in your household?

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* 24. What is your gross monthly household income?

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

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* 26. In what town/area do you currently reside?

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* 27. Which type of health care insurance do you currently have?

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* 28. Do you utilize any of the following platforms?

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