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* 1. What is your gender?

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* 2. What is your age?

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* 3. Race/Ethnicity:

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* 4. What is your household size?

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* 5. What is your household income?

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* 6. What is your education level?

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* 7. How would you rate your overall health?

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* 8. Do you have any on-going health problems?

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* 9. What services do you need to see a doctor for?

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* 10. Have you skipped going to the doctor due to no insurance or cost of care?

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* 11. Have you applied for Medi-Cal, CMSP, or Covered California?

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* 12. Are you satisfied with the health care system in the community?

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* 13. Is there a broad variety of health services in the community?

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* 14. Is there a sufficient number of health and social services in the community?

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* 15. Is there economic opportunity in the community?

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* 16. In the last 2 years have you had a:

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* 17. Have you been to the hospital; in the last 24 months without insurance?

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