2013 Community Health Assessment- Community Survey
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1. General Health

 
On behalf of the Allegany County Department of Health, Allegany/Western Steuben Rural Health Network, Cuba Memorial Hospital,and Jones Memorial Hospital; thank you for participating in the 2013 Community Health Assessment-Community Survey.

The following survey is only for adults 18 years of age and older. It is an opportunity for you to voice your opinion about our community's health and wellness. As well, health care leaders will gain knowledge about our current health care system, learn important information about our community's health status, and find new ways to support our community in becoming the healthiest county in New York State. We encourage all Allegany County residents to participate. It’s completely confidential.

We appreciate your help! Surveys must be completed and received via the on-line survey or by mail to AWSRHN, 85 North Main Street, Suite 4, Wellsville, New York 14895, no later than July 1, 2013. The survey takes about fifteen minutes.

Once again, thank you for your help!
1. Would you say your health is:
2. How tall are you without shoes? (Please use whole numbers only, no decimals.)
3. How much do you weigh? (Please use whole numbers only, no decimals.)
4. Do you smoke?
5. If Yes to the above question:
6. In the past year, have you been advised to lose weight by your health care provider?
7. How would you describe your weight?
8. Would you like to lose weight?
9. What are your barriers to weight loss?
10. Have you been told by your health care provider that you have diabetes?
11. When was the last time you saw any health care provider for diabetes related care?
12. Have you been told by your health care provider that you have respiratory disease; i.e. asthma, COPD?
13. When was the last time you saw any health care provider for respiratory related care?
14. Have you been told by a health care provider that you have heart disease?
15. When was the last time you saw any health care provider for heart related care?
16. During the past 12 months, have you been tested for any Sexually Transmitted Disease (STD) or HIV?
STDHIV
Yes
No
Don't Know
17. If yes, where did you get tested? (check all that apply)
STDHIV
Doctor's office
Health Clinic
County Health Department
Hospital
Location outside my county
18. If no, what was the main reason for not getting tested? (check all that apply)
STDHIV
Not sexually active
I do not think that I am at-risk
Did not have the time
Cannot afford
Cannot find a doctor who speaks my language
Too far to travel
Did not have transportation
Do not like going/afraid to go
Did not have childcare
19. In the past 12 months, did you go for?
YesNo
Diabetes Testing
Blood Pressure Testing
Cholesterol Testing
Cancer Screening
Nutrition Education
Weight Loss Programs
Mental Health
Family Planning Services
HIV Testing
STD Testing
20. Are you or your partner currently pregnant or have been pregnant in the past 5 years?
21. What was the mother's age at the birth of her first child?
22. Is there a history of diabetes in your immediate family (mother, father, brother, sister)?
23. Have you been told by a health care provider that you have Pre-Diabetes?
24. If you have diabetes, have you been told by a doctor/nurse that you have complications as a result of your diabetes? (check all that apply)
25. If you have diabetes, when was your last Hemoglobin (Hb) A1C test?
26. Is there a history of heart problems in your immediate family (mother, father, brother, sister)?
27. Have you or anyone in your immediate family (mother, father, brother, sister) been diagnosed with a mental health illness?
28. Have you or anyone in your immediate family (mother, father, brother, sister) been diagnosed with a alcohol and/or other drug addiction?
29. If you are living with a chronic illness, what do you do to manage your disease? (Mark all that apply)
30. Have you or a family member ever gone without prescription medications?
YesNoN/A
Me
Family member
31. In the past year, have you ever received a flu shot?
32. Have you fallen in the last 12 months?
33. Do you have a fear of falling?