Rural Solutions Community Health Care Survey: Logan, Phillips, and Sedgwick Counties 2010
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1. Introduction

Rural Solutions, an organization that brings community and health care
service providers together, has received funds from the Colorado
Department of Public Health and Environment to improve health care
services in this region. Rural Solutions is asking you, as a resident
of this area, to complete this survey that will help us understand
your health care needs.

To complete the survey,answer the questions below either
by clicking on the answer or typing in an answer as appropriate
to the question. You may leave the survey at any time by clicking
"exit survey" found in the right hand corner of your screen, and
your answers will be saved. When you have completed the survey click
"Done" and the survey will be submitted. You will not receive
any notification after you click "Done". We thank you very much for
your participation in this important survey!

1. In general, would you say your health is:

In general, would you say your health is: Excellent

Very Good

Good

Fair

Poor

2. About how long has it been since you and family members last visited a doctor for a routine checkup?
(A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition)

	1-12 months ago	1-2 years ago	2-5 years ago	More than 5 years ago	Don't know	Never
You	*About how long has it been since you and family members last visited a doctor for a routine checkup? (A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition) You 1-12 months ago	You 1-2 years ago	You 2-5 years ago	You More than 5 years ago	You Don't know	You Never
Spouse	Spouse 1-12 months ago	Spouse 1-2 years ago	Spouse 2-5 years ago	Spouse More than 5 years ago	Spouse Don't know	Spouse Never
Children	Children 1-12 months ago	Children 1-2 years ago	Children 2-5 years ago	Children More than 5 years ago	Children Don't know	Children Never

3. Is there one particular clinic, health center, doctor's office, or other place where you usually go if you are sick or need advice about your health?

Is there one particular clinic, health center, doctor's office, or other place where you usually go if you are sick or need advice about your health? Yes

More than one place

Don't know/not sure

4. Which ONE of these best describes the health care coverage for you and your family?

	Private	Employer Sponsored	CHP+	Medicaid	Medicare	CICP	Other	None
You	*Which ONE of these best describes the health care coverage for you and your family? You Private	You Employer Sponsored	You CHP+	You Medicaid	You Medicare	You CICP	You Other	You None
Spouse	Spouse Private	Spouse Employer Sponsored	Spouse CHP+	Spouse Medicaid	Spouse Medicare	Spouse CICP	Spouse Other	Spouse None
Children	Children Private	Children Employer Sponsored	Children CHP+	Children Medicaid	Children Medicare	Children CICP	Children Other	Children None

5. Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?

Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost? Yes

Don't know/Not sure

6. Do you feel that healthcare services are easily accessible when needed for you and your family?

Do you feel that healthcare services are easily accessible when needed for you and your family? Yes

Sometimes

7. Where do you usually go for non-emergency health services?

Where do you usually go for non-emergency health services? Health Department

Hospital Emergency Room

Walk-in Clinic

Chiropractor

Private Physician

Clinic

I don’t go

Other (please specify)

8. Where is your usual source for healthcare?

Where is your usual source for healthcare? Haxtun Family Medical Center

Northeast CO Department of Health and Family Planning in Holyoke

Family Practice of Holyoke

Northeast CO Health Department- Sterling

Salud Family Care Clinic- Sterling

Family Care Clinic-Sterling

Northeast CO Health Department- Julesburg

Valley Medical Clinic- Julesburg

None

Other (please specify)

9. How many miles do you travel roundtrip for health care?

How many miles do you travel roundtrip for health care?

10. Have you ever had problems getting medicine prescribed by your doctor? (Please check all answers that apply)

Have you ever had problems getting medicine prescribed by your doctor? (Please check all answers that apply) Yes

I have a high co-pay

I did not have transportation

My medical insurance does not cover prescription

There is not a Pharmacy in my town

I did not have money to pay for my prescription

Other - please specify in box below

Other (please specify)

11. What problems do you face using your community health services? (Please check all that apply)

What problems do you face using your community health services? (Please check all that apply) The medical care I need is not available

Financial

Child Care

I have no transportation

Lack of Insurance

The distance I have to travel

Cultural Barriers

Language Barriers

Other (please specify)

12. What medical services are NOT available to you in your community?

What medical services are NOT available to you in your community? Regular Physician

Heart Specialist

Mental Health Services

Dentist

Specialist

13. Do you or family members get specialist care locally or out of the area? (Please check any that apply)

	Locally	Out of area	Have not seen a specialist
You	*Do you or family members get specialist care locally or out of the area? (Please check any that apply) You Locally	You Out of area	You Have not seen a specialist
Family members	Family members Locally	Family members Out of area	Family members Have not seen a specialist

14. Do you or your family members currently have any of the following problems with your health? (Please check all that apply)

Do you or your family members currently have any of the following problems with your health? (Please check all that apply) Heart problems

Problems with your blood pressure (too high or too low)

Type 1 diabetes

Type 2 diabetes

Overweight

Other (please specify)

15. Does anyone in your family smoke or chew tobacco?

	Yes	No	Would like to quit
You	*Does anyone in your family smoke or chew tobacco? You Yes	You No	You Would like to quit
Family Member	Family Member Yes	Family Member No	Family Member Would like to quit

16. Where do you usually find out about community resources? (Please check all that apply)

Where do you usually find out about community resources? (Please check all that apply) School

Radio

Workplace

Church

T. V.

Clinic

Friends

A Resource Center

Health Department

Newspaper

Other (please specify)

17. Which ethnic identification do you use? (Please check all that apply)

Which ethnic identification do you use? (Please check all that apply) White

Hispanic

Mexican

Latino American

African American

American Indian

Asian

Other (please specify)

18. Gender

Gender Male

Female

19. Total number of years lived in this community (Please check one)

Total number of years lived in this community (Please check one) Less than 1 year

1-5 years

6-15 years

More than 15 years

20. Level of education completed (Please check one)

Level of education completed (Please check one) No high school

Some high school

Completed high school

Some college

Completed college

Some graduate school

Completed graduate school

21. Income per year (Please check one)

Income per year (Please check one) Less than $10,000

$10,001 - $20,000

$20,001 - $30,000

$30,001 - $40,000

$40,001 - $50,000

Over $50,001

22. Number of people in your household? (Please check one)

Number of people in your household? (Please check one) 4 or less

5-10

Greater than 10

23. Age (Please check all that apply)

	Under 18	18 - 34	35 - 54	55 - 64	65+
You	*Age (Please check all that apply) You Under 18	You 18 - 34	You 35 - 54	You 55 - 64	You 65+
Spouse	Spouse Under 18	Spouse 18 - 34	Spouse 35 - 54	Spouse 55 - 64	Spouse 65+
Children	Children Under 18	Children 18 - 34	Children 35 - 54	Children 55 - 64	Children 65+

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Rural Solutions Community Health Care Survey: Logan, Phillips, and Sedgwick Counties 2010Exit this survey >>

1. Introduction

1. In general, would you say your health is:

2. About how long has it been since you and family members last visited a doctor for a routine checkup? (A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition)

3. Is there one particular clinic, health center, doctor's office, or other place where you usually go if you are sick or need advice about your health?

4. Which ONE of these best describes the health care coverage for you and your family?

5. Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?

6. Do you feel that healthcare services are easily accessible when needed for you and your family?

7. Where do you usually go for non-emergency health services?

8. Where is your usual source for healthcare?

9. How many miles do you travel roundtrip for health care?

10. Have you ever had problems getting medicine prescribed by your doctor? (Please check all answers that apply)

11. What problems do you face using your community health services? (Please check all that apply)

12. What medical services are NOT available to you in your community?

13. Do you or family members get specialist care locally or out of the area? (Please check any that apply)

14. Do you or your family members currently have any of the following problems with your health? (Please check all that apply)

15. Does anyone in your family smoke or chew tobacco?

16. Where do you usually find out about community resources? (Please check all that apply)

17. Which ethnic identification do you use? (Please check all that apply)

18. Gender

19. Total number of years lived in this community (Please check one)

20. Level of education completed (Please check one)

21. Income per year (Please check one)

22. Number of people in your household? (Please check one)

23. Age (Please check all that apply)

Rural Solutions Community Health Care Survey: Logan, Phillips, and Sedgwick Counties 2010
Exit this survey >>

2. About how long has it been since you and family members last visited a doctor for a routine checkup?
(A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition)