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http://ActionSlo.org Health 1) About how far do you live from your child/children’s Elementary School?
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http://ActionSlo.org Health 2) About how far do you live from your child/children’s Junior High or Middle School?
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http://ActionSlo.org Health 3) About how far do you live from your child/children’s High School?
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http://ActionSlo.org Health 4) How does/do your Elementary school child/children usually get to school?
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http://ActionSlo.org Health 5) How does/do your Middle or Junior High School child/children usually get to school?
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http://ActionSlo.org Health 6) How does/do your High School child/children usually get to school?
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http://ActionSlo.org Health 7) Are you aware of any efforts at your child’s Elementary School to provide healthier food options and increase physical activity?
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http://ActionSlo.org Health 8) Which of the following would encourage your child(ren) to walk or bike to school more frequently?
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http://ActionSlo.org Health 9) Are you aware of any efforts at your child’s Junior High or Middle School to provide healthier food options and increase physical activity?
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http://ActionSlo.org Health 10) Are you aware of any efforts at your child’s High School to provide healthier food option and increase physical activity?
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http://ActionSlo.org Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region North Coast
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http://ActionSlo.org Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region North County
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http://ActionSlo.org Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region San Luis Obispo
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http://ActionSlo.org Health 11) During a typical school week, how much of your child’s afterschool time is spent in the following activities? Region South County
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http://ActionSlo.org Health 12) Which of the following would encourage your child(ren) to do more physical activity?
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http://ActionSlo.org Health 13) Do you or does anyone in your household, have a permanent physical or mental impairment that substantially limits a major life activity, such as bathing, dressing, stair climbing, shopping, or managing one’s money?
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http://ActionSlo.org Health 14) Who helps that person perform these activities?
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http://ActionSlo.org Health 15) Are you, or is anyone else in your household, the caregiver to…? Region North Coast
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http://ActionSlo.org Health 15) Are you, or is anyone else in your household, the caregiver to…? Region North County
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http://ActionSlo.org Health 15) Are you, or is anyone else in your household, the caregiver to…? Region San Luis Obispo
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http://ActionSlo.org Health 15) Are you, or is anyone else in your household, the caregive to…? Region South County
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http://ActionSlo.org Health 16) Does your employer try to help with healthier eating and physical activity, which might include providing stress management classes, subsidizing health club memberships, or paying for weight reduction programs?
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http://ActionSlo.org Health 17) Would you say, in general, your mental health, which includes stress, depression and problems with emotions, is…
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http://ActionSlo.org Health 18) Have you felt the need to discuss problems or situations with a mental health professional, but not had the money or insurance to do so?
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http://ActionSlo.org Health 19) Have you felt the need to talk to a mental health professional, but were concerned others treat you differently if they found out?
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http://ActionSlo.org Health 20) Do you have health insurance?
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http://ActionSlo.org Health 21) Why don’t you have health insurance?
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http://ActionSlo.org Health 22) Does that include insurance through:
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http://ActionSlo.org Health 23) At this time, are you covered by Medicare?
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http://ActionSlo.org Health 24) Does your health insurance cover…? Region North Coast
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http://ActionSlo.org Health 24) Does your health insurance cover…? Region North County
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http://ActionSlo.org Health 24) Does your health insurance cover…? Region San Luis Obispo
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http://ActionSlo.org Health 24) Does your health insurance cover…? Region South County
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http://ActionSlo.org Health 25) Do you have a regular source of health care?
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http://ActionSlo.org Health 26) When you need health care, do you usually go to a…
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http://ActionSlo.org Health 27) If you do not have a regular source of health care, what is the one main reason?
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http://ActionSlo.org Health 28) Have you or a member of your household needed health care in the past year and been unable to receive it because you could not afford it?
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http://ActionSlo.org Health 29) Do you have a regular source of dental care?
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http://ActionSlo.org Health 30) How long has it been since you last visited a dentist for a routine check up?
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http://ActionSlo.org Health 31) How long has it been since your child(ren) visited a dentist for a routine check up?
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http://ActionSlo.org Health 32) Which of these dental activities does your child do at home?
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http://ActionSlo.org Health 33) Have you completed an Advance Health Care Directive, or other legal health care document, such as a Durable Power of Attorney for Health Care, Living Will, or Health Care Proxy with the past 5 years?
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http://ActionSlo.org Health 34) How many days a week do you engage in physical activity, such as brisk walking or gardening, for a combined total of 30 minutes or more?
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http://ActionSlo.org Health 35) On average, do you eat 5 or more serving of fruits and vegetables every day?
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http://ActionSlo.org Health 36) In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at work, at home, or at fast-food restaurants, carryout or drive through.
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http://ActionSlo.org Health 37) On average, does your child eat 5 or more servings of fruit and vegetables every day?
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http://ActionSlo.org Health 38) On average, does your teen eat 5 or more servings of fruit and vegetables every day?
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http://ActionSlo.org Health 39) How concerned are you about helping your child to eat healthy? Would you say you are…
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http://ActionSlo.org Health 40) Considering all types of alcoholic beverages, in the past 30 days, about how many times did you have (4 if female; 5 if male) or more drinks on an occasion?
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http://ActionSlo.org Health 41) Do you smoke cigarettes every day, some days, or not at all?
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http://ActionSlo.org Health 42) In the past 12 months, have you quit smoking for one day or longer?
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http://ActionSlo.org Health 43) In the past 30 days, has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere inside your home?
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http://ActionSlo.org Health 44) Have there been any non-smokers present in your home, while someone was smoking?
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