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* 1. How would you describe yourself?

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* 2. What is your age range?

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* 3. What is your marital status?

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* 4. Household income?

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* 5. How would you describe your race?

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* 6. What is your ethnicity?

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* 7. What is the highest level of school you have completed?

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* 8. Please describe your work?

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* 9. Housing status?

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* 10. Children in the family household under 18 years of age:

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* 11. Town of residence:

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* 12. There is easy access to healthy foods within my community.

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* 13. There is easy access to recreation within my community.

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* 14. I feel safe within my neighborhood.

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* 15. Were you ever unemployed as a direct result of the pandemic?

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* 16. Did you lose housing as a result of the pandemic?

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* 17. Are you up to date on your Covid-19 Vaccination Schedule (primary series, two boosters)?

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* 18. How would you rate your current physical health?

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* 19. In the past 30 days, did you eat fresh (fresh, frozen, canned) fruit:

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* 20. In the past 30 days, did you eat fresh (fresh, frozen, canned) vegetables:

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* 21. In the past 30 days, did you participate in any intentional physical activity outside of your professional life (walk, golf, run, etc.)?

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* 22. Have you ever struggled with illicit drug use?

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* 23. Has someone you know ever struggled with illicit drug use?

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* 24. Have you ever struggled with misuse of prescription drugs?

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* 25. Has someone you know ever struggled with illicit drug use?

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* 26. Do you currently smoke cigarettes every day, some days, or not at all?

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* 27. Do you currently use e-cigarettes or vape everyday, some days or not at all?

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* 28. Do your kids, to the best of your knowledge, smoke cigarettes?

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* 29. Do your kids, to the best of your knowledge, smoke e-cigarettes or vape?

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* 30. If pregnant, do you smoke cigarettes, e-cigarettes or vape everyday, some days or not at all?

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* 31. During the past 30 days, how many days per week did you have at least one alcoholic beverage (one defined as 12 oz of beer, 5 oz of wine, 1.5 oz of spirits)?

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* 32. Considering all types of alcoholic beverages, how many times during the past 30 days did you have (5 for men, 4 for women) or more drinks (one drink defined as 12 oz of beer, 5 oz of wine, 1.5 oz of spirits) on one occasion?

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* 33. In the past 12 months, have you gone to the doctor for an annual physical exam?

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* 34. Is your child up to date on their school vaccinations or are currently on track to meet the vaccination requirements?

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* 35. Are you up to date on all relevant vaccinations (excluding Covid-19)?

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* 36. Have you ever been told by a health professional that you have Type 2 Diabetes?

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* 37. Has a health professional ever told you that you have Cardiovascular Disease (Valvular disease, cardiomyopathy, atherosclerosis, angina, etc.) ?

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* 38. Have you ever been told by a health professional that you have high blood pressure (hypertension)?

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* 39. Has a health professional ever told you that you had cancer?

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* 40. Has a health professional ever told you that you had Chronic Obstructive Pulmonary Disease (COPD, emphysema or chronic bronchitis)?

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* 41. Has a health professional ever told you that you have asthma?

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* 42. In the past 12 months, has a health professional ever told you that your BMI classified you as overweight or obese?

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* 43. In the past 12 months, has a health professional ever told you that your child’s BMI classified them as overweight or obese?

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* 44. In the past year, have you experienced a week or longer of lower-than-normal interest in activities that you usually enjoy?

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* 45. In the past year, have you experienced an “attack” of fear, panic or anxiety?

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* 46. In the past year, have you contemplated suicide?

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* 47. In the past year, have you ever sought out services for your mental health?

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* 48. If yes to above, was it hard to find mental health services?

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* 49. Do you have any kind of healthcare coverage, including health insurance, prepaid plans or government plans?

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* 50. When was the last time you were at the dentist for a routine teeth cleaning/exam?

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* 51. How many of your permanent teeth have been removed because of tooth decay or gum disease?

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* 52. Was there a time in the past 12 months when you needed to see a doctor but could not due to cost?

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* 53. Have you ever experienced barriers in access to proper healthcare?

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* 54. Have you ever had a barrier to accessing food?

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* 55. Do you use government assistance such as SNAP, foodbank, WIC, etc?

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* 56. Do you suffer from seasonal allergies?

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* 57. Do you consider your home free of dust?

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* 58. In the past 2 years, have you had your home tested for radon?

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* 59. Do you have reasonable access to walkable side walks/walking paths in your community?

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* 60. I am satisfied with the response of the police.

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