COMMUNITY NEEDS ASSESSMENT SURVEY (INDIVIDUAL) 2013

 
St. Francis Hospital - The Heart Center is conducting a Community Health Needs Assessment Survey. By answering these questions, you will help us identify the most important health needs in your community so that we can develop goals to meet them.
1. What are the biggest health issues or concerns in your community? (Check all that apply)
2. What keeps people in your community from seeking medical treatment? (Check all that apply)
3. What is needed to improve the health of your family and neighbors? (Check all that apply)
4. What health screenings or education/information services are needed in your community? (Check all that apply)
5. If you or someone in your family were ill and required medical care, where would you go? (Check one)
6. Where do you and your family get most of your health information? (Check all that apply)
7. When seeking care, which hospital would you visit first? (Check one)
8. Have you had a routine physical exam in the past two years?
*
9. What is your gender?
*
10. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 11363 or 94305)
*
11. Which category below includes your age?
12. What is your racial/ethnic identification?
13. What is your highest level of education?
14. Do you have health insurance?
15. Would you like to receive additional information about free or low-cost health programs at St. Francis Hospital?
Powered by SurveyMonkey
Check out our sample surveys and create your own now!