AEDF Healthcare Needs Assessment
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1. Default Section
1
. I am a resident of this Algiers zip code:
I am a resident of this Algiers zip code:
70114
70131
2
. How satisfied are you with the current healthcare services being provided in Algiers?
Please indicate your satisfaction level on a scale from 1 - 10, where 1 = Very Dissatisfied and 10 = Very Satisfied
1 - Very Dissatisfied
2
3
4
5
6
7
8
9
10 - Very Satisfied
Satisfaction Level
*
How satisfied are you with the current healthcare services being provided in Algiers? Please indicate your satisfaction level on a scale from 1 - 10, where 1 = Very Dissatisfied and 10 = Very Satisfied Satisfaction Level 1 - Very Dissatisfied
Satisfaction Level 2
Satisfaction Level 3
Satisfaction Level 4
Satisfaction Level 5
Satisfaction Level 6
Satisfaction Level 7
Satisfaction Level 8
Satisfaction Level 9
Satisfaction Level 10 - Very Satisfied
If you are dissatisfied, please comment on why:
3
. Where are you currently receiving healthcare services?
Where are you currently receiving healthcare services?
Algiers
Other Westbank
Eastbank
Other
Not receiving services
4
. If you are receiving healthcare services outside of Algiers, would you be willing to receive these services in Algiers?
If you are receiving healthcare services outside of Algiers, would you be willing to receive these services in Algiers?
Yes
No
5
. I would like to see these additional service(s) provided in Algiers:
I would like to see these additional service(s) provided in Algiers:
Primary Care
Pediatrics
OB/GYN
Geriatrics
Physical Therapy/Occupational Therapy/Speech Therapy
Behavioral / Mental Health
Other (please specify)
6
. Name and Address: (optional)
Name and Address: (optional)
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