Community Health Needs Assessment Survey
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1. In general, which of the following best describes your health?

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):

	Yes	No	Do not know
Arthritis	*Have you ever been told by a doctor or other health professional that you have (fill in all that apply): Arthritis Yes	Arthritis No	Arthritis Do not know
Heart problems	Heart problems Yes	Heart problems No	Heart problems Do not know
Diabetes (sugar)	Diabetes (sugar) Yes	Diabetes (sugar) No	Diabetes (sugar) Do not know
High blood pressure	High blood pressure Yes	High blood pressure No	High blood pressure Do not know
Asthma	Asthma Yes	Asthma No	Asthma Do not know
Emphysema or bronchitis (breathing problems)	Emphysema or bronchitis (breathing problems) Yes	Emphysema or bronchitis (breathing problems) No	Emphysema or bronchitis (breathing problems) Do not know
High blood cholesterol	High blood cholesterol Yes	High blood cholesterol No	High blood cholesterol Do not know
Uncorrectable vision problems or blindness	Uncorrectable vision problems or blindness Yes	Uncorrectable vision problems or blindness No	Uncorrectable vision problems or blindness Do not know
Hearing loss	Hearing loss Yes	Hearing loss No	Hearing loss Do not know
Cancer	Cancer Yes	Cancer No	Cancer Do not know
Had a stroke	Had a stroke Yes	Had a stroke No	Had a stroke Do not know
Chronic disease(s) of the nervous system (such as MS) or muscles	Chronic disease(s) of the nervous system (such as MS) or muscles Yes	Chronic disease(s) of the nervous system (such as MS) or muscles No	Chronic disease(s) of the nervous system (such as MS) or muscles Do not know
Problems of the stomach or intestines	Problems of the stomach or intestines Yes	Problems of the stomach or intestines No	Problems of the stomach or intestines Do not know
Weight problem	Weight problem Yes	Weight problem No	Weight problem Do not know

3. In the past 12 months, have you had a (fill in all that apply):

	Yes	No	Do not know
General health exam	*In the past 12 months, have you had a (fill in all that apply): General health exam Yes	General health exam No	General health exam Do not know
Blood pressure check	Blood pressure check Yes	Blood pressure check No	Blood pressure check Do not know
Cholesterol check	Cholesterol check Yes	Cholesterol check No	Cholesterol check Do not know
Flu shot	Flu shot Yes	Flu shot No	Flu shot Do not know
Blood stool test	Blood stool test Yes	Blood stool test No	Blood stool test Do not know
Dental exam/ teeth cleaned	Dental exam/ teeth cleaned Yes	Dental exam/ teeth cleaned No	Dental exam/ teeth cleaned Do not know
IF FEMALE: Pap test	IF FEMALE: Pap test Yes	IF FEMALE: Pap test No	IF FEMALE: Pap test Do not know
IF FEMALE: Breast exam by a health care provider	IF FEMALE: Breast exam by a health care provider Yes	IF FEMALE: Breast exam by a health care provider No	IF FEMALE: Breast exam by a health care provider Do not know
IF FEMALE: Breast x-ray or mammogram	IF FEMALE: Breast x-ray or mammogram Yes	IF FEMALE: Breast x-ray or mammogram No	IF FEMALE: Breast x-ray or mammogram Do not know

4. In the past 5 years, have you had a (fill in all that apply):

	Yes	No	Do not know
Hearing test	*In the past 5 years, have you had a (fill in all that apply): Hearing test Yes	Hearing test No	Hearing test Do not know
Eye exam	Eye exam Yes	Eye exam No	Eye exam Do not know
Diabetes check	Diabetes check Yes	Diabetes check No	Diabetes check Do not know
Skin cancer screen	Skin cancer screen Yes	Skin cancer screen No	Skin cancer screen Do not know
Pneumonia shot	Pneumonia shot Yes	Pneumonia shot No	Pneumonia shot Do not know
IF AGE 40 or OLDER: rectal exam	IF AGE 40 or OLDER: rectal exam Yes	IF AGE 40 or OLDER: rectal exam No	IF AGE 40 or OLDER: rectal exam Do not know
IF AGE 50 or OLDER: a colonoscopy	IF AGE 50 or OLDER: a colonoscopy Yes	IF AGE 50 or OLDER: a colonoscopy No	IF AGE 50 or OLDER: a colonoscopy Do not know
IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA	IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA Yes	IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA No	IF MALE and AGE 40 or OLDER: a prostate cancer screenlPSA Do not know

5. IF FEMALE: How often do you examine your breasts for lumps?

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?

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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