Questions from Adult Survey
1. Would you say that in general your health is excellent, very good, good, fair or poor?
2. Now thinking about your physical health, which includes physical injury and illness, for how many days during the past 30 days was your physical health not good?
3. Now 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?
4. During the past 30 days, for about how many days did poor physical or mental health prevent you from during your usual activities, such as self-care, work, or recreation? Unmet Needs and Quality of Life
5. Do you have any untreated problems or conditions that you think could be helped by a medical, dental, or mental health professional or counselor?
6. Are you limited in any way in any activities because of any impairment of health problems?
7. During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work, or recreation?
8. During the past 30 days, for about how many days have you felt sad, blue or depressed?
9. During the past 30 days, for about how many days have you felt worried, tense, or anxious?

Health Care Coverage
10. Do you have nay kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?
11. Do you have Medicare?
12. Does your health insurance cover the cost of prescription medications?
13. Have you ever not been able to get medications prescribed for you because of the cost? Health Care Access
14. About how long has it been since you last visited a doctor or other health car provider such as a physician's assistant or a clinical nurse specialist for a routine check up?
15. Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
16. How would you rate your satisfaction with your overall health care? Would you say excellent, very good, good, fair, or poor? 17. Thinking of the distance or time you travel to get to the place you usually go to, how would you rate the convenience of that place? Would you say excellent, very good, good, fair, or poor?
18. Is there one particular doctor or health professional who you usually go to when you need routine medical care?

Oral Health and Dental Care Coverage
19. About how long has it been since you last visited a dentist or other dental health professional for a routine checkup?
20. Do you have any kind of insurance coverage that pays for some or all of your routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medi-Cal or Medicare?
21. Was there a time during the last 12 months when you needed to see a dentist, but could not because of the cost?
22. Do you currently have any untreated dental problems?

Weight Control
23. About how much do you weigh without shoes? About how tall are you without shoes?
24. Are you now trying to lose weight?
25. In the past 12 months has a doctor, nurse, or other health professional given you advice about your weight?

Exercise
26. How often do you do vigorous activities for at least 20 minutes that cause heavy sweating or large increases in breathing or heart rate?
27. Overall, how would you describe your physical condition and fitness level? Would you say excellent, very good, good, fair or poor?
28. In general, do you think that you get as much physical activity or exercise as you should?

Nutrition
29. In total, about how many servings of fruit and vegetables do you have on the average each day?
30. How often do you eat at least 2 well-balanced meals per day? Would you say everyday, almost everyday, sometimes, rarely, or never?
31. In the past 30 days, have you been concerned about having enough food for yourself or your family?

Hypertension
32. About how long has it been since you last had your blood pressure taken by a doctor, nurse, or other health professional?
33. Have you ever been told by a doctor, a nurse, or other health professional that you have high blood pressure?

Cholesterol
34. Have you ever had your blood cholesterol checked?
35. About how long has it been since you last had your blood cholesterol checked?
36. Have you ever been told by a doctor, a nurse, or other health professional that your blood cholesterol is high?

Diabetes
37. Have you ever been told by a doctor that you have diabetes?

Stressors and Coping
38. In the past 12 months, would you say you experienced lots of stress, a moderate amount, relatively little stress, almost no stress, or no stress at all?
39. During the past 12 months, have you been seen by a doctor or mental health professional, such as a psychiatrist, psychologist, or social worker for any mental health related problems or concerns including stress, alcohol, drug, or personal or family problems?
40. Do you have any mental health, stress, alcohol, drug, or personal or family problems that you think could be helped by a doctor or mental health professional during the next 12 months?
41. Overall, how good a job do you feel you do in coping with the stresses in your life? Would you say excellent, very good, good, fair, or poor?

Tobacco Use
42. Do you now smoke cigarettes every day, some days, or not at all?
43. On the average, how many cigarettes do you now smoke a day?
44. Would you like to completely quit smoking cigarettes?
45. How many minutes or hours per day are you close enough to people who are smoking that you can smell the smoke?
46. Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?

Alcohol
47. During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
48. Specifically, during the past month, how many days per week or per month did you drink any alcoholic beverages, on average? A drink is one can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor?
49. How many drinks containing alcohol do you have on a typical day when you are drinking?
50. Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
51. Have you ever thought that you might have a drinking problem?
52. During the past month, how many times, if any, have you driven when you've had perhaps too much to drink?
53. During the past month, how many times, if any, have you ridden with a driver who has had perhaps too much to drink?

Inappropriate Medication/Drug Use
54. In the past 12 months, have you used any medicines, drugs, or substances, not including alcohol, to get high or to make you feel good, without a prescription or with greater frequency or quantity than prescribed?
55. Have you ever thought that you might have a drug abuse problem?

Injury Control
56. Do you believe that you are exposed to hazards or other safety problems at your workplace, such as toxic chemicals, unsafe machines, or a work environment that is noisy, polluted, or uncomfortable?
57. What specific hazards do you believe you are exposed to?
58. Are there any firearms now kept in or around your home? Include those kept in a garage, outdoor storage area, car, truck, or other motor vehicle.
59. Are any of the firearms handguns, such as pistols or revolvers?
60. Is there a firearm in or around your home that is now both loaded and unlocked?
61. How often do you use seat belts when you drive or ride in a car? Would you say always, nearly always, often, sometimes, rarely, or never?

Reproductive Issues
62. A mammogram is an X-ray of each breast to look for cancer. Have you ever had a mammogram?
63. A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical breast exam?
64. How long has it been since you had your last mammogram?
65. About how often do you examine your breasts for lumps?
66. How long has it been since you had your last Pap smear?
67. Have you had a hysterectomy?
68. What kinds of birth control are you or your partner using now?

Men's Issues
69. A Prostate Specific Antigen or PSA blood test is used by some doctors to check for prostate cancer. Have you ever had a PSA test?
70. How often do you examine your testicles for lumps?

Sexual Behavior
71. During the past 12 months, with how many people have you had sexual intercourse?
72. Do any of these situations apply to you? You have used intravenous drugs in the past year. You have been treated for a sexually transmitted or venereal disease in the past year. You tested positive for having HIV, the virus that causes AIDS. You have had anal sex without a condom in the past year.
73. In the past 5 years, have you been treated for a sexually transmitted disease or venereal disease?
74. What are your chances of getting infected with HIV, the virus that causes AIDS, Would you say high, medium, low, or none? Immunizations
75. During the past 12 months, have you had a flu shot? This vaccination is usually given in the fall and protects against influenza for the flu season.
76. Have you ever had a pneumonia vaccination?

Environmental Issues
77. How concerned are you about pollution of the air, water, or ground which may be affecting the health of Santa Barbara county residents? Would you say you are very concerned, somewhat concerned, a little concerned, or not concerned at all?
78. What is the cause or source of your concern?
79. How concerned are you about children's exposure to toxic chemicals like lead, pesticides, and other chemicals in the environment? Would you say very concerned, somewhat concerned, a little concerned, or not concerned at all?

Health Information Issues
80. Please tell me if each program or service I mention is of interest to you at all. Alternative/Complimentary Medicine
81. Have you every used any of the following non-traditional or alternative therapies when you were sick, for general wellness, or for relaxation?

Interpersonal Violence
82. Do you feel safe in your current relationship or relationships?
83. Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?
84. By whom?

Health Department Attitudes
85. Overall, how good a job do you think the Santa Barbara County Public Health Department is doing serving your community? Would you say excellent, very good, good, fair, or poor?