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How Healthy Is The Capital District? A Community Survey
1. Survey Questions
Thank you for taking the time to complete the 21 question survey below.
Your input is valuable and all responses are confidential.
1
. Where do you currently reside?
Where do you currently reside?
Albany County
Rensselaer County
Schenectady County
Other County
2
. What ZIP CODE do you live in?
What ZIP CODE do you live in?
3
. What best describes you?
What best describes you?
White Male
White Female
Non-White Male
Non-White Female
4
. Which of the following best describes you?
Which of the following best describes you?
Employed for Wages
Self-Employed
Out Of Work
A Homemaker
A Student
Retired
5
. Do you have health insurance?
Do you have health insurance?
No Insurance
Private Health Insurance
Public Health Insurance (Medicaid,Family Health Plus, Medicare
Private and Public Insurance (Medicare with Private Wrap- Around)
6
. If you do not have health care coverage, what is the main reason you don't?
If you do not have health care coverage, what is the main reason you don't?
Lost Job Or Changed Employers
Spouse Or Parent Lost Job Or Changed Employers
Became Divorced Or Separated
Spouse Or Parent Died
Became Ineligible Because Of Age Or Because Left School
Employer Doesn't Offer Or Stopped Offering Coverage
Hired As Part-Time Or Cut Back To Part-Time Or Became Temporary Employee Without Benefits
Couldn't Afford To Pay The Premiums
Insurance Company Refused Coverage
Lost Medicaid Or Medical Assistance Eligiblity
Problem With Recertification For Medicaid
Other
Don't Know
7
. When was your last physical?
When was your last physical?
Within The Last Year
Two Years
Three Years
Four Years Or More
8
. Where do you go to get most of your health care services?
Where do you go to get most of your health care services?
Primary Care Physician
Specialist
Walk-In Or Urgent Care Center
Hospital Emergency Room
Community Health Center
County Health Department
Other
9
. What typically prevents you from seeking health care when you need it (select all items that apply)?
What typically prevents you from seeking health care when you need it (select all items that apply)?
Transportation
Work Schedule Restrictions or Office Wasn't Open At Time Needed
No Child Care
Distance
Language
Attitude Of Office Staff
Availability Of Doctor
Too long To Wait For An Appointment
Wait Time In Office Too Long
Doctor Not Accepting Your Insurance
Lack Of Insurance
Cannot Afford To Pay (Charges, Deductible Or Copay)
No Access For People With Disabilities
Other Pressing Life Issues Are More Important
Other Reasons
I Have No Problems Getting Care
10
. What needed health services are not available in your community?
What needed health services are not available in your community?
11
. Is there a group of people in your community (gender, age, race, neighborhood) experiencing a particular health problem that is not being adequately addressed by the health care system? If yes, please identify this group and the problem?
Is there a group of people in your community (gender, age, race, neighborhood) experiencing a particular health problem that is not being adequately addressed by the health care system? If yes, please identify this group and the problem?
12
. How many times have you visited the hospital emergency room during the past 2 years?
How many times have you visited the hospital emergency room during the past 2 years?
No Visits
Once
Twice
Three Times
Four Times
Five or More Times
13
. Sometimes people use the hospital emergency room for care when they don't have a health emergency. If you have utilized an emergency room within the past 2 years, please identify the reasons below?
Sometimes people use the hospital emergency room for care when they don't have a health emergency. If you have utilized an emergency room within the past 2 years, please identify the reasons below?
14
. Do you or someone in your household have a chronic illness? If yes, please check all that apply?
Do you or someone in your household have a chronic illness? If yes, please check all that apply?
Cancer
Asthma
Heart Disease
Stroke
Diabetes
High Blood Pressure
Depression/Anxiety/Emotional Problem
Kidney Disease
Arthritis/Rheumatism or Other Bone/Joint Diseases
15
. Do you or someone in your household with a chronic illness, identified above, have problems accessing health care services to address the illness? If so, please identify the problem?
Do you or someone in your household with a chronic illness, identified above, have problems accessing health care services to address the illness? If so, please identify the problem?
16
. How satisfied are you with the quality of health promotion and preventive care information and support you regularly receive from your primary health care provider?
How satisfied are you with the quality of health promotion and preventive care information and support you regularly receive from your primary health care provider?
Very Satisfeid
Satisfied
Not Satisfied
17
. I would be healthier if
I would be healthier if
18
. The partners of HCDI selected our top health priorities based upon the following criteria:number of people impacted, severity of illness, how preventable it is, whether it is a root cause of other illnesses,and cost to the health care system. Do you agree that the following are the top two health priorities for the Capital Region.
(a.)Access to Health Care-Having Health Insurance, Having A Regular Health Care Provider, Access to Specialists, Access to Dental Care
(b.)Chronic Diseases-Diabetes, Stroke, Diseases of the Heart, Cancer
The partners of HCDI selected our top health priorities based upon the following criteria:number of people impacted, severity of illness, how preventable it is, whether it is a root cause of other illnesses,and cost to the health care system. Do you agree that the following are the top two health priorities for the Capital Region. (a.)Access to Health Care-Having Health Insurance, Having A Regular Health Care Provider, Access to Specialists, Access to Dental Care (b.)Chronic Diseases-Diabetes, Stroke, Diseases of the Heart, Cancer
Yes
No
19
. Please identify any other health issues that you feel should be a priority focus area in future community health planning initiatives?
Please identify any other health issues that you feel should be a priority focus area in future community health planning initiatives?
20
. How satisfied are you with the quality of health promotion and preventive care information and support you regularly receive from your health care insurer?
How satisfied are you with the quality of health promotion and preventive care information and support you regularly receive from your health care insurer?
Very Satisfied
Satisfied
Not Satisfied
21
. How Familiar Are You With The Healthy Capital District Initiative?
How Familiar Are You With The Healthy Capital District Initiative?
Very
Somewhat
Not At All
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