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Community Health Needs Assessment
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1
. What is your zip code?
(As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.)
What is your zip code? (As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.)
15832, Driftwood
16748, Shinglehouse
15834, Emporium
16749, Smethport
15861, Sinnamahoning
16750, Turtlepoint
16720, Austin
16915, Coudersport
16724, Crosby
16921, Gaines
16726, Cyclone
16922, Galeton
16729, Duke Center
16923, Genesee
16730, East Smethport
16927, Harrison Valley
16731, Eldred
16937, Mills
16732, Gifford
16941, Genesee
16738, Lewis Run
16943, Sabinsville
16743, Port Allegany
16948, Ulysses
16744, Rew
16950, Westfield
16745, Rixford
16746, Roulette
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2
. What is your age?
(Please discountinue this survey if you are under the age of 18.)
What is your age? (Please discountinue this survey if you are under the age of 18.)
18-20
21-30
31-40
41-50
51-60
61-70
71-80
80+
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3
. How many individuals live in your household?
How many individuals live in your household?
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4
. Number of
Number of
adults in your household
children in your household
5
. Do you have a primary healthcare provider?
Do you have a primary healthcare provider?
Yes
No
6
. If you have a primary healthcare provider, what is his/her name?
If you have a primary healthcare provider, what is his/her name?
7
. Are you able to get an appointment with your primary healthcare provider when you need one?
Are you able to get an appointment with your primary healthcare provider when you need one?
Yes
No
Other (please specify)
8
. If you don't have a primary healthcare provider what do you do when you need medical care?
If you don't have a primary healthcare provider what do you do when you need medical care?
9
. Do you think there are enough primary healthcare providers in your area?
Do you think there are enough primary healthcare providers in your area?
Yes
No
10
. Do you have a chronic medical condition?
Do you have a chronic medical condition?
Yes
No
11
. If you have a chronic medical condition, are you receiving routine medical care for the condition?
If you have a chronic medical condition, are you receiving routine medical care for the condition?
Yes
No
12
. Has anyone in your household seen a specialist within the past 12 months?
Has anyone in your household seen a specialist within the past 12 months?
Yes
No
13
. If you or someone in your household haS seen a specialist within the last year, what type of specialist and in what town/city?
(Example: Neurologist, Erie, PA)
If you or someone in your household haS seen a specialist within the last year, what type of specialist and in what town/city? (Example: Neurologist, Erie, PA)
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14
. If a specialist was seen, did the specialist(s) require additional testing such as lab work, imaging services, cardiac tests, pulmonary tests, etc?
If a specialist was seen, did the specialist(s) require additional testing such as lab work, imaging services, cardiac tests, pulmonary tests, etc?
Yes
No
15
. If the specialist(s) ordered additional testing, was the testing performed at Charles Cole Memorial Hospital?
If the specialist(s) ordered additional testing, was the testing performed at Charles Cole Memorial Hospital?
Yes
No
16
. If the specialist(s) ordered tests and they were not performed at Charles Cole Memorial Hospital, where were they performed? (Example: MRI, Geisinger Hospital)
If the specialist(s) ordered tests and they were not performed at Charles Cole Memorial Hospital, where were they performed? (Example: MRI, Geisinger Hospital)
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17
. If you had tests performed at a location other than Charles Cole Memorial Hospital, why did you have the tests performed somewhere else?
If you had tests performed at a location other than Charles Cole Memorial Hospital, why did you have the tests performed somewhere else?
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18
. In the past year were you unable to afford a prescription medication?
In the past year were you unable to afford a prescription medication?
Yes
No
19
. Do you and/or members of your household have any type of medical insurance?
Do you and/or members of your household have any type of medical insurance?
Yes
No
20
. If you and/or someone in your household does have medical insurance, how are they insured?
If you and/or someone in your household does have medical insurance, how are they insured?
Through your work
Through your spouse's work
Through another household members' work
Through COBRA
Through a self-paid, private insurance plan
Through CHIP
Through Medicare
Through Medicaid/Medical Assistance/Access
Through the Veteran's Administration
Through Veteran Insurance-Champus/TriCare
Through Native American/Tribal benefits
Other
21
. Are you or someone in your household looking for a certain type of medical service that is not provided in your area? (Example: Endocrinology)
Are you or someone in your household looking for a certain type of medical service that is not provided in your area? (Example: Endocrinology)
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22
. Have you or someone in your household received services from Charles Cole Memorial Hospital, with the exception of emergency department visits and routine office visits, within the last year?
Have you or someone in your household received services from Charles Cole Memorial Hospital, with the exception of emergency department visits and routine office visits, within the last year?
Yes
No
23
. If you or someone in your household has received services from Charles Cole Memorial Hospital within the last year, what services were received (excluding emergency department and routine office visits)?
If you or someone in your household has received services from Charles Cole Memorial Hospital within the last year, what services were received (excluding emergency department and routine office visits)?
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24
. If you received services from Charles Cole Memorial Hospital within the last year, were you satisfied or dissatisfied?
If you received services from Charles Cole Memorial Hospital within the last year, were you satisfied or dissatisfied?
Satisfied
Dissatisfied
25
. Have you or someone in your household received services, with the exception of emergency department visits and routine office visits, within the last year some place other than Charles Cole Memorial Hospital?
Have you or someone in your household received services, with the exception of emergency department visits and routine office visits, within the last year some place other than Charles Cole Memorial Hospital?
Yes
No
26
. If you or someone in your household has received services within the last year from some place other than Charles Cole Memorial Hospital, where did you receive services (excluding emergency department and routine office visits)? (Example: Hamot, Erie, PA)
If you or someone in your household has received services within the last year from some place other than Charles Cole Memorial Hospital, where did you receive services (excluding emergency department and routine office visits)? (Example: Hamot, Erie, PA)
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27
. Have you or someone in your household used emergency department services within the last year?
Have you or someone in your household used emergency department services within the last year?
Yes
No
28
. If you received services some place other than Charles Cole Memorial Hospital, why did you choose to go some place else?
If you received services some place other than Charles Cole Memorial Hospital, why did you choose to go some place else?
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29
. If you or someone in your household did receive emergency department services, what town/city did you receive care?
If you or someone in your household did receive emergency department services, what town/city did you receive care?
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30
. If you or someone in your household did receive emergency department care, why did you need emergency care? (Example: abdominal pain)
If you or someone in your household did receive emergency department care, why did you need emergency care? (Example: abdominal pain)
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31
. Were you satisfied or dissatisfied with the emergency department care that you received?
Were you satisfied or dissatisfied with the emergency department care that you received?
Satisfied
Dissatisfied
32
. Have you or someone in your household had a healthcare concern/issue for which you did not seek medical care within the last year?
Have you or someone in your household had a healthcare concern/issue for which you did not seek medical care within the last year?
Yes
No
33
. If you or someone in your household had a concern/issue for which you didn't seek medical care, why didn't you seek care?
If you or someone in your household had a concern/issue for which you didn't seek medical care, why didn't you seek care?
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34
. Has everyone in your household had a dental check-up within the last year?
Has everyone in your household had a dental check-up within the last year?
Yes
No
35
. If no, why didn't everyone in your household have a dental check-up within the last year?
If no, why didn't everyone in your household have a dental check-up within the last year?
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36
. Do you have trouble accessing healthcare due to transportation issues?
Do you have trouble accessing healthcare due to transportation issues?
Yes
No
37
. Do you read the nutrition labels on the food you are buying?
Do you read the nutrition labels on the food you are buying?
Yes
No
38
. How would you rate your overall health?
How would you rate your overall health?
Excellent
Very Good
Good
Fair
Poor
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