Thank you for agreeing to participate in the Sauk County Health and Wellness Coalition Health Survey! As a part of our 2018 Community Health Needs Assessment, we are collecting data about the health and well-being of Sauk County residents, as well as residents from the surrounding areas. The survey only takes about 10 minutes to complete.

 Your survey response will help us to better serve our community and improve the community's health. As a thank you for completing the survey, you will be entered to win a variety of great prizes!

 All of your responses will be strictly confidential and will only be used as data for the Community Health Needs Assessment. 

What is your year of birth?

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* 1. What is your year of birth?

What is your gender identity?

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* 2. What is your gender identity?

About how much do you weigh, without shoes?

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* 3. About how much do you weigh, without shoes?

About how tall are you, without shoes? 

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* 4. About how tall are you, without shoes? 

Are you Hispanic or Latino?

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* 5. Are you Hispanic or Latino?

Which of the following do you identify most with?

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* 6. Which of the following do you identify most with?

What is your current marital status?

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* 7. What is your current marital status?

What is the highest grade level of education you have completed?

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* 8. What is the highest grade level of education you have completed?

Do you live in Sauk County?

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* 9. Do you live in Sauk County?

What is the zip code of your primary residence? 

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* 10. What is the zip code of your primary residence? 

What is your annual household income before taxes?

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* 11. What is your annual household income before taxes?

In the following list, what do you think are the three (3) most important factors for a community to be healthy?

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* 12. In the following list, what do you think are the three (3) most important factors for a community to be healthy?

In the following list, what do you think are the three (3) most important health problems in our community? (Those problems that have the greatest impact on overall community health.)

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* 13. In the following list, what do you think are the three (3) most important health problems in our community? (Those problems that have the greatest impact on overall community health.)

In the following list, what do you think are the three (3) most important risky behaviors in our community? (Those behaviors that have the greatest impact on overall community health.)

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* 14. In the following list, what do you think are the three (3) most important risky behaviors in our community? (Those behaviors that have the greatest impact on overall community health.)

How healthy do you think our community is?

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* 15. How healthy do you think our community is?

Generally speaking, would you say your health is:

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* 16. Generally speaking, would you say your health is:

Currently, what is your primary type of health coverage?

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* 17. Currently, what is your primary type of health coverage?

Did you have health insurance during all, part, or none of the past 12 months?

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* 18. Did you have health insurance during all, part, or none of the past 12 months?

Did everyone in your household have health insurance during all, part, or none of the past 12 months?

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* 19. Did everyone in your household have health insurance during all, part, or none of the past 12 months?

In the past 12 months, have you or anyone in your household not taken prescription medication due to prescription costs?

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* 20. In the past 12 months, have you or anyone in your household not taken prescription medication due to prescription costs?

Was there a time in the last 12 months that you felt you did not get the medical care you needed?

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* 21. Was there a time in the last 12 months that you felt you did not get the medical care you needed?

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