1. Do you think any of the following are health concerns in the county? Fast food restaurant density Preventable hospitalizations Limited access to healthy foods Preventable teen deaths Fall deaths Alcohol-related driving deaths Alcohol-related deaths Drug overdose deaths High blood pressure Heart disease Lung disease deaths Alzheimer's disease None of the above Don't know / not sure 2. Are there health problems faced by county residents not listed here? Yes No (skip to question 4) Don't know / not sure (skip to question 4) 3. Please list these health problems. 4. What do you think are the top three health problems in the county?5. Would you say that in general your health is… Excellent Very Good Good Fair Poor 6. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health NOT good?Please enter a number from 0 to 30.7. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health NOT good?Please enter a number from 0 to 30.8. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?Please enter a number from 0 to 30.9. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Services? Yes No (skip to question 11) 10. What is the primary source of your health care coverage? A plan purchased through an employer or union (including plans purchased through another person’s employer) A plan that you or another family member buys on your own Medicare Medicaid, or other state program TRICARE (formerly CHAMPUS), VA, or Military Alaska Native, Indian Health Service, or Tribal Health Services Some other source Don’t know / not sure 11. Do you have one person you think of as your personal doctor or health care provider? Yes, only one More than one No 12. Do you have one person you think of as your personal dentist or dental care provider? Yes, only one More than one No 13. About how long has it been since you last visited a doctor for a routine checkup? Within the past year (anytime less than 12 months ago) Within the past 2 years (more than 1 year but less than 2 years ago) Within the past 5 years (more than 2 years but less than 5 years ago) 5 or more years ago Never Don't know / not sure 14. Including all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists, how long has it been since you last visited a dentist or a dental clinic for any reason? Within the past year (anytime less than 12 months ago) Within the past 2 years (more than 1 year but less than 2 years ago) Within the past 5 years (more than 2 years but less than 5 years ago) 5 or more years ago Never Don't know / not sure 15. What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up? Clinic or health center Doctor's office or HMO Hospital emergency room Hospital outpatient department Some other place Don't go to one place most often (skip to question 17) Don't get preventative care anywhere (skip to question 17) 16. Is this place located in the county? Yes No Don't know / not sure 17. During the past 12 months, have you seen or talked to any of the following health care providers about your own health? (Select all that apply) A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker An optometrist, ophthalmologist, or eye doctor A foot doctor A chiropractor A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist A nurse practitioner, physician assistant, or midwife A doctor who specializes in women's health (an obstetrician/gynecologist) A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist) A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine) None of the above (skip to question 19) 18. Which of the following health care providers were located OUTSIDE of the county? (Select all that apply A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker An optometrist, ophthalmologist, or eye doctor A foot doctor A chiropractor A physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist A nurse practitioner, physician assistant, or midwife A doctor who specializes in women's health (an obstetrician/gynecologist) A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist) A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine) None of the above 19. During the past 12 months, was there any time when you needed any of the following, but didn't get it because you couldn't afford it? (Select all that apply) Prescription medicines Medical care Eyeglasses Dental care Mental health care or counseling None of the above 20. During the past 12 months, how many times have you gone to a hospital emergency room about your own health?0 (skip to question 22)12345678910111213141516 or moreDon't know / not sure (skip to question 22)21. Which of the following applies to your last emergency room visit? (Select all that apply) No place else to go Doctor's office/clinic not open Health provider advised you to go Problem was too serious for the clinic Only a hospital could help you The ER is the closest provider You get most of your care at the ER You arrived by ambulance or other emergency vehicle 22. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. How long has it been since you had your last sigmoidoscopy or colonoscopy?Within the past year (anytime less than 12 months)Within the past 2 years (more than 1 year but less than 2 years ago)Within the past 3 years (more than 2 years but less than 3 years ago)Within the past 5 years (more than 3 years but less than 5 years ago)Within the past 10 years (more than 5 years but less than 10 years ago)10 or more years agoI have never received a sigmoidoscopy or colonoscopy23. During the past 12 months, have you had either a flu shot, or a flu vaccine that was sprayed in your nose? Yes No 24. Have you received a tetanus shot in the past 10 years?Yes, received TdapYes, received tetanus shot, but not TdapYes, received tetanus shot but not sure what typeNo, did not receive any tetanus shot in the past 10 yearsDon't know / not sure25. Have you received a Pertussis vaccine in the past 10 years?YesNoDon't know / not sure26. Have you received any of the following vaccines in your lifetime? (Select all that apply) Pneumonia Human Papillomavirus (HPV) Shingles Chicken pox Measles (MMR) Hepatitis A Hepatitis B Polio Rabies None of the above Don't know / not sure 27. Which of the following statements describe your personal beliefs regarding vaccination? (Select all that apply) I could get a serious disease if I am not vaccinated It is important for me to get vaccinated in order to prevent the spread of disease in my community Vaccines may cause chronic disease (such as diabetes, asthma, or immune system problems) Vaccines are not tested enough for safety Vaccines are given to prevent diseases I am not likely to get The benefits of vaccination outweigh the risks Vaccines may cause learning disabilities in children (such as autism) Other None of the above 28. Has a doctor, nurse, or other health professional ever told you that you had any of the following? (Select all that apply) Alzheimer's disease or dementia Anemia Arthritis Asthma Cancer (COMPLETE QUESTION 30) Chronic Obstructive Pulmonary Disease (COPD) Chronic pain Diabetes (COMPLETE QUESTION 29) Epilepsy Fibromyalgia Graves' disease Heart disease Hepatitis A, B, or C High blood pressure High cholesterol HIV/AIDS Inflammatory bowel disease (ulcerative colitis, Crohn's, etc) Kidney disease Mood disorder (depression, bipolar, etc) Multiple sclerosis Osteoporosis Parkinson's disease Pneumonia Stroke None of the above 29. The following statements describe self-care activities related to your diabetes. Thinking about your self-care over the last 8 weeks, please select the statements that apply to you. (Select all that apply) I check my blood sugar levels with care and attention The food I choose to eat makes it easy to achieve optimal blood sugar levels I keep all doctors' appointments recommended for my diabetes treatment I take my diabetes medication as prescribed Occasionally I eat lots of sweets or other foods rich in carbohydrates I record my blood sugar levels regularly I tend to avoid diabetes-related doctors' appointments I do regular physical activity to achieve optimal blood sugar levels I strictly follow the dietary recommendations given by my doctor or specialist I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control I avoid physical activity, although it would improve my diabetes I tend to forget to take or skip my diabetes medication Sometimes I have real 'food binges' Regarding my diabetes care, I should see my medical practitioner(s) more often I tend to skip planned physical activity My diabetes self-care is poor None of the above 30. What type of cancer were you diagnosed with? (Select all that apply) Bladder Bone Brain Breast Cervical Colon Esophageal Head/neck Heart Hodgkin's Lymphoma Larynx Leukemia Liver Lung Melanoma Neuroblastoma Non-Hodgkin's Lymphoma Oral Ovarian Pancreatic Pharyngeal Prostate Rectal Renal Skin Stomach Testicular Uterine Other 31. In general, how healthy is your overall diet?ExcellentVery goodGoodFairPoor32. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?0123456789101112131415 or moreDon’t know / not sure33. During the past 7 days, on how many days did you eat fruits or vegetables?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure34. In a typical week, on how many days do you participate in moderate-intensity sports, fitness, or recreational activities that cause a small increase in breathing or heart rate, such as brisk walking, bicycling, swimming, or golf, for at least 10 minutes continuously?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure35. In a typical week, on how many days do you participate in vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate, like running or basketball, for at least 10 minutes continuously?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure36. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure37. Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Yes No 38. Please select all of the following statements that describe situations that are difficult for you to manage by yourself, or without the use of special equipment. Walk a quarter of a mile, or about 3 city blocks Walk up 10 steps without resting Stand or be on your feet for about 2 hours Sit for about 2 hours Stoop, bend, or kneel Reach up over your head Use your fingers to grasp or handle small objects Lift or carry something as heavy as 10 pounds, such as a full bag of groceries Push or pull large objects like a living room chair Go out to things like shopping, movies, or sporting events Participate in social activities such as visiting friends, attending clubs and meetings, going to parties Do things to relax at home or for leisure (reading, watching TV, sewing, listening to music) None of the above 39. During the past 30 days, how many days PER WEEK did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure40. During the past 30 days, on the days you drank, about how many drinks did you drink on average?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure41. Considering all types of alcoholic beverages, how many times during the past 30 days did you (for males) have 5 or more drinks on an occasion, or (for females) have 4 or more drinks on an occasion?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure42. During the past 30 days, how many times have you driven when you've had perhaps too much to drink?0 days1 day2 days3 days4 days5 days6 days7 daysDon't know / not sure43. Have you smoked at least 100 cigarettes in your entire life? Yes No (skip to question 46) Don't know / not sure 44. Do you now smoke cigarettes every day, some days, or not at all? Every day Some days Not at all 45. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? Yes No Don’t know / not sure 46. Do you now use smokeless tobacco products every day, some days, or not at all? Every day Some days Not at all 47. Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life? Yes No (skip to question 49) 48. Do you now use e-cigarettes or other electronic vaping products every day, some days, or not at all? Every day Some days Not at all 49. During the past 30 days, on how many days did you use marijuana or cannabis?1 day2 days3 days4 days5 days6 days7 days8 days9 days10 days11 days12 days13 days14 days15 days16 days17 days18 days19 days20 days21 days22 days23 days24 days25 days26 days27 days28 days29 days30 daysNone (skip to question 51)Don't know / not sure50. Which of the following best describes your marijuana or cannabis use? Medicinal (as prescribed by a physician) Medicinal (non-prescribed) Recreational 51. During the past 30 days, on how many days did you use illicit drugs?1 day2 days3 days4 days5 days6 days7 days8 days9 days10 days11 days12 days13 days14 days15 days16 days17 days18 days19 days20 days21 days22 days23 days24 days25 days26 days27 days28 days29 days30 daysNone (skip to question 53)Don't know / not sure52. What types of illicit drugs did you use? (Select all that apply) Amphetamine/Methamphetamine Ecstasy Hallucinogens (such as PCP or LSD) Opioids (such as Heroin, Fentanyl, or Carfentanil) Steroids Stimulants (such as Cocaine or Crack) Other 53. During the past 30 days, on how many days did you abuse prescription drugs?1 day2 days3 days4 days5 days6 days7 days8 days9 days10 days11 days12 days13 days14 days15 days16 days17 days18 days19 days20 days21 days22 days23 days24 days25 days26 days27 days28 days29 days30 daysNone (skip to question 56)Don't know / not sure54. What types of prescription drugs did you abuse? (Select all that apply) Antidepressants/Anti-anxiety (such as Celexa, Lexapro, Prozac, or Zoloft) Opioids (such as OxyContin, Percocet, Vicodin, or Demerol) Anticonvulsants (such as Neurontin or Lyrica) Sedative (such as Xanax, Valium, Ativan, or Lunesta) Stimulants (such as Concerta or Adderall) Steroids (such as Dianabol or Androgel) Other 55. Were any of the following medications prescribed to you by a physician? (Select all that apply) No Antidepressants/Anti-anxiety (such as Celexa, Lexapro, Prozac, or Zoloft) Opioids (such as OxyContin, Percocet, Vicodin, or Demerol) Anticonvulsants (such as Neurontin or Lyrica) Sedative (such as Xanax, Valium, Ativan, or Lunesta) Stimulants (such as Concerta or Adderall) Steroids (such as Dianabol or Androgel) Other 56. During the past 12 months, did you ever seriously consider attempting suicide?YesNo (skip to question 58)57. During the past 12 months, how many times did you actually attempt suicide?0 times1 time2 times3 times4 times5 times6 or more times58. Please select all of the following statements that apply to the time period before you were 18 years of age. You lived with someone who was depressed, mentally ill, or suicidal You lived with someone who was a problem drinker or alcoholic You lived with someone who used illegal street drugs or who abused prescription medications You lived with someone who served time or was sentenced to serve time in a prison, jail, or other correctional facility Your parents were separated or divorced Your parents or adults in your home slapped, hit, kicked, punched, or beat each other up A parent or adult in your home hit, beat, kicked, or physically hurt you in any way (not including spanking) A parent or adult in your home swore at you, insulted you, or put you down Someone at least 5 years older than you or an adult touched you sexually Someone at least 5 years older than you or an adult tried to make you touch sexually Someone at least 5 years older than you or an adult forced you to have sex None of the above 59. In the past 12 months, with how many people have you had sexual intercourse?0 (skip to question 62)12345678910 or moreDon’t know / not sure60. In the past 12 months, about how often have you had sexual intercourse without using a condom?NeverLess than half of the timeAbout half of the timeNot always, but more than half of the timeAlways61. The last time you had sexual intercourse, what method did you or your partner use to prevent pregnancy? (Select all that apply) No method was used to prevent pregnancy Birth control pills Condoms An IUD (such as Mirena or ParaGard) or implant (such as Implanon or Nexplanon) A shot (such as Depo-Provera), patch (such as Ortho Evra), or birth control ring (such as NuvaRing) Tubal ligation, vasectomy, or other permanent sterilization Withdrawal or some other method 62. Which of the following best describes the location of your current residence?Concord TownshipEastlake CityFairport HarborGrand River VillageKirtland CityKirtland HillsLakeline VillageLeroy TownshipMadison TownshipMadison VillageMentor CityMentor-on-the-LakeNorth Perry VillagePainesville CityPainesville TownshipPerry TownshipPerry VillageTimberlake VillageWaite Hill VillageWickliffe CityWilloughby CityWilloughby HillsWillowick City63. About how long have you lived in your present neighborhood?Less than 1 year1 to 3 years4 to 10 years11 to 20 yearsMore than 20 years64. Is your home a house, an apartment, a manufactured/mobile home, or some other type of residence?HouseApartment, flatManufactured/mobile homeNontransient hotel, motel, etcPermanent in transient hotel, motelRooming house or boarding houseBoat or recreational vehicleTent, cave, or railroad carUnoccupied site for manufactured/mobile home, trailer, or tentGroup quartersOther65. Thinking about the other buildings within a half block from your home, are there any of the following? (Select all that apply)Single-family detached homesSingle-family townhouses or row housesApartment buildingsManufactured/mobile homesNone of the above66. During the last 6 months, did you call the police to report something that happened to you which you thought was a crime? Yes No 67. During the last 6 months, did anything which you thought was a crime happen to you, but you did not report to the police? Yes No 68. Are you currently…Employed (skip to question 70)Self-employed (skip to question 70)Out of work for 1 year or moreOut of work for less than 1 yearHomemaker (skip to question 70)Student (skip to question 70)Retired (skip to question 70)Unable to work69. What is the main reason you are not working?Taking care of house or familyGoing to schoolRetiredOn a planned vacation from workOn family or maternity leaveTemporarily unable to work for health reasonsHave job or contract and off-seasonOn layoffDisabledOther70. Please select all of the statements below that apply to your current financial situation. I am worried right now about... Not having enough money for retirement Being able to pay medical costs of a serious illness or accident Being able to maintain the standard of living I enjoy Being able to pay medical costs for normal healthcare Not having enough money to pay for my children's college Not having enough to pay my normal monthly bills Not being able to pay my rent, mortgage, or other housing costs Not being able to make the minimum payments on my credit cards None of the above 71. Please select all of the statements below that characterize your ability to afford the food you needed in the past 12 months. I cut the size of my meals or skipped meals because there wasn’t enough money for food The food that I bought just didn't last, and I didn't have money to get more I couldn't afford to eat balanced meals I ate less than I felt I should because there wasn't enough money for food I was hungry but didn't eat because there wasn't enough money for food None of the above 72. How do you usually get to the store (or stores) where you do most of your grocery shopping?In my carIn a car that belongs to someone I live withIn a car that belongs to someone who lives elsewhereWalkRide bicycleBus, subway, or other public transitTaxi or other paid driverSomeone else delivers groceriesNo usual mode of traveling to storeOther73. At any time in the past 12 months, did you or anyone in your family receive benefits from the WIC program, that is, the Women, Infants, and Children program? Yes No Don't know / not sure 74. Of these income groups, which best represents your current total household income before taxes?Less than $20,000$20,000 to $39,999$40,000 to $59,999$60,000 to $79,999$80,000 to $99,999$100,000 to $119,999$120,000 to $139,999$140,000 to $159,999$160,000 or greaterDon’t know / not sure75. How many vehicles are owned, leased, or available for regular use by the people who currently live in your household?0123456 or more76. What is the highest level of education you have received?Less than 12th grade12th grade, no diplomaHigh school graduate or GED equivalentSome college, no degreeAssociate degreeBachelor's degreeMaster's degreeDoctoral or professional degree77. Are you now married, widowed, divorced, separated, never married, or living with a partner?MarriedWidowedDivorcedSeparatedNever marriedLiving with partner78. What is your age (in years)?12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182838485868788899091929394959697989910010110210310410579. How tall are you without shoes?3’0"3’1"3’2"3’3"3’4"3’5"3’6"3’7"3’8"3’9"3’10"3’11"4’0"4’1"4’2"4’3"4’4"4’5"4’6"4’7"4’8"4’9"4’10"4’11"5’0"5’1"5’2"5’3"5’4"5’5"5’6"5’7"5’8"5’9"5’10"5’11"6’0"6’1"6’2"6’3"6’4"6’5"6’6"6’7"6’8"6’9"6’10"6’11"7’0"7’1"7’2"7’3"7’4"7’5"7’6"7’7"7’8"7’9"7’10"7’11"80. How much do you weigh without shoes (in pounds)?808182838485868788899091929394959697989910010110210310410510610710810911011111211311411511611711811912012112212312412512612712812913013113213313413513613713813914014114214314414514614714814915015115215315415515615715815916016116216316416516616716816917017117217317417517617717817918018118218318418518618718818919019119219319419519619719819920020120220320420520620720820921021121221321421521621721821922022122222322422522622722822923023123223323423523623723823924024124224324424524624724824925025125225325425525625725825926026126226326426526626726826927027127227327427527627727827928028128228328428528628728828929029129229329429529629729829930030130230330430530630730830931031131231331431531631731831932032132232332432532632732832933033133233333433533633733833934034134234334434534634734834935035135235335435535635735835936036136236336436536636736836937037137237337437537637737837938038138238338438538638738838939039139239339439539639739839940040140240340440540640740840941041141241341441541641741841942042142242342442542642742842943043143243343443543643743843944044144244344444544644744844945045145245345445545645745845946046146246346446546646746846947047147247347447547647747847948048148248348448548648748848949049149249349449549649749849950050150250350450550650750850951051151251351451551651751851952052152252352452552652752852953053153253353453553653753853954054154254354454554654754854955055155255355455555655755855956056156256356456556656756856957057157257357457557657757857958058158258358458558658758858959059159259359459559659759859960081. What is your race? (Select all that apply) African American American Indian or Alaskan Native Asian Caucasian Native Hawaiian or Pacific Islander Other 82. How would you describe your ethnic background? Hispanic or Latino Not Hispanic or Latino 83. What language(s) do you usually speak at home? English Spanish Other 84. Using your usual language, do you have difficulty communicating, for example, understanding or being understood?No difficultySome difficultyA lot of difficultyCannot do at all / unable to do85. Including you, how many people live in your home?1 (skip to question 88)23456Don’t know / not sure86. How many of these people are under 18 years of age?0123456Don’t know / not sure87. Please indicate the relationships of the people living in your home. (Select all that apply) Opposite-sex husband/wife/spouse Opposite-sex unmarried partner Same-sex husband/wife/spouse Same-sex unmarried partner Biological son or daughter Adopted son or daughter Stepson or stepdaughter Grandchild Father or mother Brother or sister Parent-in-law Son-in-law or daughter-in-law Other relative Foster child Housemate/roommate Roomer/boarder Other nonrelative 88. What is your sex? Male (skip to the end of the survey) Female 89. A mammogram is an x-ray taken only of the breast by a machine that presses against the breast. When did you have your most recent mammogram?A year ago or lessMore than 1 year but not more than 2 yearsMore than 2 years but not more than 3 yearsMore than 3 years but not more than 5 yearsOver 5 years agoI have never received a mammogram90. A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab. When did you have your most recent Pap test?A year ago or lessMore than 1 year but not more than 2 yearsMore than 2 years but not more than 3 yearsMore than 3 years but not more than 5 yearsOver 5 years agoI have never received a Pap test92. Did you experience any of the following during or as a result of your pregnancy (or pregnancies)? (Select all that apply) Hemorrhage Cardiovascular complication Infection Embolism Preeclampsia/eclampsia Decline in mental health Other None of the above Δ
