This survey has been developed to get your opinions about health problems in our community and the results will be used to identify issues we can address through community action.

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* 1. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 2. What is your age?

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* 3. What is your gender?

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* 4. What race or ethnic group do you most identify with?

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* 5. Are you Hispanic/Latino?

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* 6. Do you have any health care coverage including health insurance, prepaid plans such as HMOs, or government plans such as Medicaid or Medicare?

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* 7. During the past 12 months, did you see a health care provider?

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* 8. During the past 12 months, did you see a dental care provider?

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* 9. Have you been told by a health care provider that you have any of the following conditions? (Check all that apply).

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* 10. What is your main form of transportation?

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* 11. What are the 3 main reasons people in our community are not active more often?

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* 12. What are the 3 main reasons people in our community do not eat healthy foods more often?

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* 13. Do you smoke cigarettes?

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* 14. Do you use any other type of tobacco, such as cigars or smokeless tobacco?

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* 15. Do you support smoke free workplaces, including restaurants and bars?

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* 16. Are you exposed to cigarette smoke at work?

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* 17. What are the 3 most important health problems in our community?

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* 18. What are the 3 most important factors for a healthy community?

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* 19. How would you rate the overall health of our community?

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* 20. Job status: Are you currently...?

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* 21. What is your household income?

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* 22. What are the 3 main reasons you and/or others in our community do not seek health care?

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* 23. Thank you for your time in completing this survey. Your answers will help us as we strive to work with you to make the community a healthier place for all of us! Do you have any additional comments?

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