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* 1. In the following list, what do you think are the most important things needed for a healthy Madison County? (Please check all that apply)

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* 2. In the following list, what do you think are the greatest health problems in Madison County? (Please check all that apply)

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* 3. In the following list of ways a community can support the physical health of its residents, which are the most successful in Madison County? (Please check all that apply)

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* 4. How would you rate Madison County as a "Safe County"?

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* 5. How would you rate Madison County as a "Healthy County"?

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* 6. In the following list, what do you think are the most risky behaviors in Madison County? (Please check all that apply)

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* 7. Listed below are some factors related to injury. Which safety problem(s) are most important for people in Madison County? (Please check all that apply)

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* 8. Madison county should have or needs more of the following physical activity opportunities available, (Please check all that apply)

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* 9. How many days during the past 30 days were you not able to work or do your daily activities because of physical illness or disability ? (Please write the number of days in the box below)

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* 10. How many days during the past 30 days were you not able to work or do your daily activities because of mental illness? (Please write the number of days in the box below)

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* 11. I have been told by a doctor, nurse, or other health professional that I have the following health problem, (Please check all that apply)

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* 12. When I am sick, I usually go for treatment at: (Please select only one response)

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* 13. How would you rate your own personal safety?

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* 14. How would you rate your own personal health?

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* 15. Do you currently have children in your household under the age of 18?

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* 16. When my children are sick, I usually take them for treatment to: (Please select only one response)

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* 17. My children get their immunizations at: (Please select only one response)

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* 18. Madison Country needs more of the following health services. (Please check all that apply)

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* 19. Sex:

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* 20. Age:

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* 21. Education:

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* 22. Race:

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* 23. What is/are your primary reason(s) for being in Madison County? (Please check all that apply)

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* 24. How do you pay for your health care? (Please check all that apply)

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