8. In your opinion, what areas need additional education or attention in our community?
(Check all that apply)
a) Abuse / Violence
j) Neglect
s) Teen Pregnancy
b) Aging (Dementia)
k) Nutrition
t) Tobacco Use
c) Alcohol
l) Obesity
u) Uninsured
d) Alternative Medicine
m) Ozone (Air Quality)
v) Vaccinations / Immunizations
e) Child Care
n) Pain Management
w) Water Quality
f) Chronic Diseases
o) Poverty
x) Wellness Education
g) Family Planning / Birth Control
p) Preventative Healthcare
y) Drugs
h) Lead Exposure
q) Sexually Transmitted Diseases
z) Gambling
i) Mental Illness
r) Suicide
aa) Injury Prevention
Other (please specify below)
PART II: YOUR HEALTH PRACTICES
9. In general, how would you best describe your health? (Choose one)
? Very Good
? Good
? Fair
? Poor
? Very Poor
10. Compared to a year ago, how would you rate your overall health now?
? Much better than a year ago
? About the same
? Much Worse than a year ago
11. Do you have a personal healthcare provider you use for primary care?
? Yes
? No
If Yes, Please give Physician's name / Specialty / City
12. Have you had a physical in the past 12 months?
? Yes
? No
If no, why not? (Be specific)
13. Check which health practices you follow:
Yes
(Check one box per row)
No
N/A
If over 50, have you had a colonoscopy?
?
?
?
If male over 40, do you have annual
prostate exams?
?
?
?
If female over 40, do you have annual
mammograms?
?
?
?
If female, do you have a pap smear
every other year?
?
?
?
Do you get 2.5 hours a week of
moderately intense physical activity?
?
?
?
Do you visit your dentist annually?
?
?
?
Do you visit your eye doctor annually?
?
?
?
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