Community Health Needs Assessment Survey

1. In general, which of the following best describes your health?
2. Have you ever been told by a doctor or other health professional that you have (fill in all that apply):
YesNoDo not know
Heart problems
Diabetes (sugar)
High blood pressure
Emphysema or bronchitis (breathing problems)
High blood cholesterol
Uncorrectable vision problems or blindness
Hearing loss
Had a stroke
Chronic disease(s) of the nervous system (such as MS) or muscles
Problems of the stomach or intestines
Weight problem
3. In the past 12 months, have you had a (fill in all that apply):
YesNoDo not know
General health exam
Blood pressure check
Cholesterol check
Flu shot
Blood stool test
Dental exam/ teeth cleaned
IF FEMALE: Pap test
IF FEMALE: Breast exam by a health care provider
IF FEMALE: Breast x-ray or mammogram
4. In the past 5 years, have you had a (fill in all that apply):
YesNoDo not know
Hearing test
Eye exam
Diabetes check
Skin cancer screen
Pneumonia shot
IF AGE 40 or OLDER: rectal exam
IF AGE 50 or OLDER: a colonoscopy
IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA
5. IF FEMALE: How often do you examine your breasts for lumps?
6. IF FEMALE: If you have been pregnant within the last 5 years, when in your pregnancy did you first see a doctor or nurse?
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