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* 1. What county do you live in?

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* 2. My zip code is:

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* 3. I have this type of health care coverage:

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* 4. A doctor, nurse, or other healthcare provider, told me that I have the following: (Check all that apply)

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* 5. My main form of transportation is:

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* 6. I think these are 3 main reasons why people in our community do not seek health care:

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* 7. I think these are 3 main reasons that prevent people from being physically active in our community:

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* 8. I think these are 3 main reasons that prevent people in our community from eating healthy foods:

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* 9. I think these are the 3 most important health concerns in our community:

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* 10. I think these are the 3 most important factors for a healthy community:

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* 11. I would rate the overall health of our community as:

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* 12. I use the following tobacco products. (Check all that apply)

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* 13. I agree with the idea of smoke free workplaces, including restaurants and bars.

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* 14. I am exposed to secondhand smoke (i.e. smoke from someone else who may be smoking in my home, workplace, or public place).

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* 15. If you are exposed to secondhand smoke, where? (Check all that apply):

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* 16. In the last 2 days, how many fruits and vegetables have you eaten?

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* 17. In the last week, how many times were you physically active or exercised?

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* 18. How important is it to be physically active or exercise?

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* 19. How important is it to eat fruits and vegetables?

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* 20. In the last 30 days when I bought fruits and vegetables, they were? (Check all that apply)

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* 21. What age range are you?

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* 22. Are you male or female?

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* 23. Which race/ethnic group do you most identify with? (Choose only one)

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* 24. Are you of Hispanic, Latino or Spanish origin?

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* 25. What is your current employment status? (Choose all that apply)

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* 26. What was your total family income last year before taxes? (Choose only one)

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* 27. What is the highest level of school, college, or vocational training you finished? (Choose only one)

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