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1.
In general, how would you rate your overall health? (select one)
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2.
The recommendation for physical activity is 30 minutes a day 5 days a week (2.5 hours per week). Which of the following reasons prevent you from gettting this much physical activity? (select all that apply)
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3.
One recommendation to maintain a healthy lifestyle is to eat atleast 5 servings of fruits and vegtables a day (not french fries or potatoe chips). Which would you consider the main reason that you do not eat this way. (select one)
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4.
Have you visited a doctor (primary care) in the past 12 months?
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5.
Have you visited a specialist (OBGYN, dermatologist, allergist, etc.) in the past 12 months?
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6.
Where do you go most often for health care when you are sick?
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7.
Where do you go when you need your yearly check-up or physical? (select all that apply)
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8.
was there a time, in the past 12 months, where you needed to see a doctor, but didnt? If yes, why didnt you see a doctor?
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9.
Select the diseases, challengaes or conditions that you have been diagnosed with by a health care provider. (select one)
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10.
Do you feel that you have what you need to manage these conditions?
What do you feel you need to help you manage these conditons?
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11.
Which of the following are the top 5 things that impact health in our community? (Select up to 5)
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12.
Select the diseases, challenges or conditions that you think are a concern for our commnity. (select all that apply)
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13.
What are our major strengths/resources in our community related to health care?
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14.
What resources could be used differently to improve health care?
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15.
Please select the highest level of education you have completed.
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16.
Please select the option that best describes your health insurance provider.
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17.
Race/Ethnicity (check all that apply)
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18.
what is your average annual household income?
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19.
what is your age?
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20.
What is your gender?
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21.
What is your zip code?
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