Community Wellness Survey
The purpose of this survey is to understand the overall community wellness and access to health care in Lyon County. Your answers will be used by Healthy Communities Coalition staff to help determine the impact and the needs of the community. Your answers will be kept confidential. This survey should take 5 minutes or less of your time.

Your participation in this survey is voluntary and you may stop taking it at any time.

If you have any questions, please contact Lisa Godenick at lgodenick@healthycomm.org

By filling out this survey you are providing voluntary consent to participate in this survey.
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This section's questions are about access to health care, emotional wellness, and social wellness. Access to health care is important to the overall health of the community. Emotional wellness is the ability to successfully handle life’s daily stressors and adapt to change; social wellness involves building healthy and supportive relationships and genuinely connecting with those around you.
1. I have adequate access to my primary care doctor.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
2. I see my primary care doctor regularly.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
3. I feel I am able to cope with my daily stress.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
4. Access to behavioral health services is important to me.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
5. I have adequate access to behavioral health services.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
6. I have adequate access to oral health services.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
7. I regularly see my dentist.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
8. Prescription drug use is having a negative impact on my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
9. Would you be interested in participating in a mindfulness activity in your community, such as yoga or meditation?
10. What kinds of stress-reduction activities or programs would you like Healthy Communities Coalition to offer in your community?
Your answer
11. I see the value in alternative pain management.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
12. I support doctors prescribing methadone to help people with their addiction.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
13. I support people receiving counseling as part of their treatment.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
14. I have social opportunities in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
15. My community is a safe place.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
16. I have at least one close friend whom I trust and confide in.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
17. I take pride in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
18. I support community/school gardens.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
19. I support nutrition and wellness classes/information.
Please make a selection along the scale that most closely matches how you feel about the following statement.
Strongly Disagree
Strongly Agree
20. What would create a better feeling of community where you live? Why?
Your answer
This section's questions relate to physical and environmental wellness and your perception of substance use in your community. Physical wellness includes watching what you put into your body, how much physical activity you get, and how much sleep you get. Environmental health includes what surrounds you each day at home, work, or in your neighborhood as well as how you interact with the natural environment. Substance use involves excessive use of a drug (such as alcohol, narcotics, tobacco, marijuana, etc.).
21. I engage in exercise 2-3 times per week for at least 30 minutes.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Never
Always
22. I eat fresh fruits and vegetables daily.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Never
Always
23. Do you have a primary care provider?
24. Have you seen a healthcare professional in the past 12 months?
25. Have you seen a primary care provider for a physical or wellness check in the past 12 months?
26. Do you have health insurance?
Please select all that apply:
27. Tobacco use is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
28. Vaping is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
29. Marijuana is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
30. Misuse of prescription medication (e.g. Adderall, Xanax, Valium) is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
31. Alcohol is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
32. Illicit drug use (e.g. cocaine, methamphetamine, ecstasy) is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
33. Please select any events you are interested in attending in your community.
Select all that apply:
34. Spirituality and/or faith-based activities are important.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
35. I take time to appreciate my surroundings & nature.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
36. I think it’s important to conserve natural resources.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
37. I engage in environmentally-friendly behaviors (e.g. riding a bike, walking places, recycling when possible).
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
This section's questions relate to intellectual and occupational wellness. Intellectual wellness refers to active participation in scholastic, cultural, and community activities. Occupational wellness refers to the ability to have a steady job and the balance between work and leisure time.
38. Volunteering is important to me.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
39. There are many opportunities to volunteer in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
40. Unemployment is a problem in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
41. There are many opportunities for employment in my community.
Please make a selection along the scale that most closely matches how you feel about the preceding statement.
Strongly Disagree
Strongly Agree
42. I feel as though I have a sense of purpose.
43. I seek out meaning in my life.
44. I am able to balance my current job with the rest of my life.
45. What kinds of resources could you or your family use?
Your answer
The next questions relate to your demographics.
46. What is your gender?
47. How old are you?
48. What is your race/ethnicity?
Select all that apply:
49. What is the highest level of education you have completed?
50. Where do you currently live?
Please select an answer nearest to your home.
Thank you for taking time to complete this survey!
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number D04RH31780 and the Rural Health Care Services Outreach Grant Program title for $200,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

This institution is an equal opportunity provider.
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