1. In what zip code is your home located?

2. Which category below includes your age?

3. How many children age 17 or younger live in your household?

4. Which ethnic group do you most identify with ?

5. Are you now married, widowed, divorced, separated, or never married?

6. What is the highest level of school you have completed or the highest degree you have received?

7. What is your current household income?

8. Which of the following best describes your health insurance status?

9. Where did you get this survey?

10. In your opinion,what do most people die from in your community? (check only one)

11. If you get sick,where would you go first? (ie: flu,upset stomach,blood pressure,diabetes)

12. If you get sick,where do you go if you need hospital care? (check only one)

13. In your opinion,what is the biggest health issue of concern in your community?
(select up to 3 )

14. In your opinion,what do you think is the main reason that keeps people in your community from seeking medical treatment? (select only one)

15. How do you rate your own health?

16. Which of the following health related behaviors describe you? (select all that apply)

17. Does anyone in your household use tobacco products? ( smoke,chew,dip)

18. Where do you and your family get most of your health information? (select all that apply)

19. Where do you get your information on community news/events?