Community Needs Assessment Survey for BaltimoreCommunity Needs Assessment Survey for Baltimore

2. What is your age range?

What is your age range? Under 18 years

19-24 years

25-30 years

31-40 years

41-50 years

51-60 years

61-65 years

Greater than 65 years

3. Gender?

Gender? Male

Female

4. What is your race/ethnicity?

What is your race/ethnicity? African American

Asian/Pacific Islander

Caucasian

Hispanic

Other

5. What is the highest level of education completed?

What is the highest level of education completed? Some High School

High School Graduate

Some College

Bachelor's Degree

Graduate Degree

Doctoral/Professional Degree

6. What is your employment status? (Check all that apply)

What is your employment status? (Check all that apply) Employed Full Time

Employed Part Time

Unemployed

Full Time Student

Part Time Student

Homemaker

Retired

Disabled

Other (please specify)

7. Form(s) of insurance you currently have? (Check all that apply)

Form(s) of insurance you currently have? (Check all that apply) Private-traditional

Managed Care (HMO, PPO)

Medicaid/MChip

Medicare

Health Savings Account

Not Sure

Do Not Have Health Insurance

Other (please specify)

8. Select the option that best describes your current health status:

Select the option that best describes your current health status: Poor

Fair

Good

Very Good

Excellent

9. Select the number of days you were too sick to work or do activities in the last 3 months:

Select the number of days you were too sick to work or do activities in the last 3 months: 0 days

1-2 days

3-5 days

6-10 days

10 or more days

10. Which option best describes the time frame of your last physical or routine doctor's visit?

Which option best describes the time frame of your last physical or routine doctor's visit? Never had a routine physical or doctor's visit

More than 5 years

Within 2-5 years

Within 19-24 months

Within 13-18 months

Within 12 months

11. Which of these options best describe where you receive your health care regularly? (Check all that apply)

Which of these options best describe where you receive your health care regularly? (Check all that apply) Doctor or Primary Care Physician's Office

Hospital Emergency Room

Health Department Clinic

Dentist

Urgent Care Center

Eye Doctor

Community Clinic

Other (please specify)

12. Are you able to to visit the doctor when needed?

Are you able to to visit the doctor when needed? Never

Seldom

Sometimes

Always

13. If you are not able to see a doctor when needed, please choose the options that best describe why? (Check all that apply)

If you are not able to see a doctor when needed, please choose the options that best describe why? (Check all that apply) No health insurance

Too expensive/Can't afford it

Lack of transportation

Doctor is too far away

14. Please indicate whether you feel the following health issues are a problem in your community:

	Not Sure	Not a Problem	Moderate Problem	Serious Problem
Behavioral	*Please indicate whether you feel the following health issues are a problem in your community: Behavioral Not Sure	Behavioral Not a Problem	Behavioral Moderate Problem	Behavioral Serious Problem
Substance Abuse/Addiction	Substance Abuse/Addiction Not Sure	Substance Abuse/Addiction Not a Problem	Substance Abuse/Addiction Moderate Problem	Substance Abuse/Addiction Serious Problem
Smoking/Tobacco Use	Smoking/Tobacco Use Not Sure	Smoking/Tobacco Use Not a Problem	Smoking/Tobacco Use Moderate Problem	Smoking/Tobacco Use Serious Problem
Mental Health/Illness	Mental Health/Illness Not Sure	Mental Health/Illness Not a Problem	Mental Health/Illness Moderate Problem	Mental Health/Illness Serious Problem
Environmental	Environmental Not Sure	Environmental Not a Problem	Environmental Moderate Problem	Environmental Serious Problem
Allergies	Allergies Not Sure	Allergies Not a Problem	Allergies Moderate Problem	Allergies Serious Problem
Asthma/Lung Diseases	Asthma/Lung Diseases Not Sure	Asthma/Lung Diseases Not a Problem	Asthma/Lung Diseases Moderate Problem	Asthma/Lung Diseases Serious Problem
Highway Safety/Traffic Accidents	Highway Safety/Traffic Accidents Not Sure	Highway Safety/Traffic Accidents Not a Problem	Highway Safety/Traffic Accidents Moderate Problem	Highway Safety/Traffic Accidents Serious Problem
Major Health Concerns	Major Health Concerns Not Sure	Major Health Concerns Not a Problem	Major Health Concerns Moderate Problem	Major Health Concerns Serious Problem
Cancer	Cancer Not Sure	Cancer Not a Problem	Cancer Moderate Problem	Cancer Serious Problem
Diabetes/Sugar	Diabetes/Sugar Not Sure	Diabetes/Sugar Not a Problem	Diabetes/Sugar Moderate Problem	Diabetes/Sugar Serious Problem
High Blood Pressure/Stroke	High Blood Pressure/Stroke Not Sure	High Blood Pressure/Stroke Not a Problem	High Blood Pressure/Stroke Moderate Problem	High Blood Pressure/Stroke Serious Problem
Heart Disease	Heart Disease Not Sure	Heart Disease Not a Problem	Heart Disease Moderate Problem	Heart Disease Serious Problem
Dental Health	Dental Health Not Sure	Dental Health Not a Problem	Dental Health Moderate Problem	Dental Health Serious Problem
Obesity/Overweight	Obesity/Overweight Not Sure	Obesity/Overweight Not a Problem	Obesity/Overweight Moderate Problem	Obesity/Overweight Serious Problem
Prenatal and Infant Health	Prenatal and Infant Health Not Sure	Prenatal and Infant Health Not a Problem	Prenatal and Infant Health Moderate Problem	Prenatal and Infant Health Serious Problem
Infectious Diseases (Flu, Hepatitis)	Infectious Diseases (Flu, Hepatitis) Not Sure	Infectious Diseases (Flu, Hepatitis) Not a Problem	Infectious Diseases (Flu, Hepatitis) Moderate Problem	Infectious Diseases (Flu, Hepatitis) Serious Problem
Sexually Transmitted Diseases	Sexually Transmitted Diseases Not Sure	Sexually Transmitted Diseases Not a Problem	Sexually Transmitted Diseases Moderate Problem	Sexually Transmitted Diseases Serious Problem
Health Care Access	Health Care Access Not Sure	Health Care Access Not a Problem	Health Care Access Moderate Problem	Health Care Access Serious Problem
Affordable Health Care	Affordable Health Care Not Sure	Affordable Health Care Not a Problem	Affordable Health Care Moderate Problem	Affordable Health Care Serious Problem
Ambulance Service	Ambulance Service Not Sure	Ambulance Service Not a Problem	Ambulance Service Moderate Problem	Ambulance Service Serious Problem
Access to Health Care	Access to Health Care Not Sure	Access to Health Care Not a Problem	Access to Health Care Moderate Problem	Access to Health Care Serious Problem
Services for the Disabled	Services for the Disabled Not Sure	Services for the Disabled Not a Problem	Services for the Disabled Moderate Problem	Services for the Disabled Serious Problem
Violence	Violence Not Sure	Violence Not a Problem	Violence Moderate Problem	Violence Serious Problem
Injury	Injury Not Sure	Injury Not a Problem	Injury Moderate Problem	Injury Serious Problem
Teen Pregnancy	Teen Pregnancy Not Sure	Teen Pregnancy Not a Problem	Teen Pregnancy Moderate Problem	Teen Pregnancy Serious Problem
Crime/Gang Related Activities	Crime/Gang Related Activities Not Sure	Crime/Gang Related Activities Not a Problem	Crime/Gang Related Activities Moderate Problem	Crime/Gang Related Activities Serious Problem
Domestic Violence	Domestic Violence Not Sure	Domestic Violence Not a Problem	Domestic Violence Moderate Problem	Domestic Violence Serious Problem
Child Abuse and Neglect	Child Abuse and Neglect Not Sure	Child Abuse and Neglect Not a Problem	Child Abuse and Neglect Moderate Problem	Child Abuse and Neglect Serious Problem
Suicide	Suicide Not Sure	Suicide Not a Problem	Suicide Moderate Problem	Suicide Serious Problem

15. Where do you get your health information? (Check all that apply)

Where do you get your health information? (Check all that apply) Family/Friends

Church

Public Library

Doctors/Nurses/Pharmacists

Hospital

Schools

Employer

Internet/Websites

Health Department

Other (please specify)

16. How often do you do the following?

	Never	Sometimes	Always	Not Applicable
Wear a seatbelt	*How often do you do the following? Wear a seatbelt Never	Wear a seatbelt Sometimes	Wear a seatbelt Always	Wear a seatbelt Not Applicable
Wear a helmet while riding a bike	Wear a helmet while riding a bike Never	Wear a helmet while riding a bike Sometimes	Wear a helmet while riding a bike Always	Wear a helmet while riding a bike Not Applicable
Drive the speed limit	Drive the speed limit Never	Drive the speed limit Sometimes	Drive the speed limit Always	Drive the speed limit Not Applicable
Avoid chewing tobacco/snuff	Avoid chewing tobacco/snuff Never	Avoid chewing tobacco/snuff Sometimes	Avoid chewing tobacco/snuff Always	Avoid chewing tobacco/snuff Not Applicable
Avoid smoking cigarettes	Avoid smoking cigarettes Never	Avoid smoking cigarettes Sometimes	Avoid smoking cigarettes Always	Avoid smoking cigarettes Not Applicable
Avoid use of illegal drugs	Avoid use of illegal drugs Never	Avoid use of illegal drugs Sometimes	Avoid use of illegal drugs Always	Avoid use of illegal drugs Not Applicable
Wash your hands after using the bathroom	Wash your hands after using the bathroom Never	Wash your hands after using the bathroom Sometimes	Wash your hands after using the bathroom Always	Wash your hands after using the bathroom Not Applicable
Wash your hands before making food	Wash your hands before making food Never	Wash your hands before making food Sometimes	Wash your hands before making food Always	Wash your hands before making food Not Applicable
Wear sunscreen	Wear sunscreen Never	Wear sunscreen Sometimes	Wear sunscreen Always	Wear sunscreen Not Applicable
Get a flu shot	Get a flu shot Never	Get a flu shot Sometimes	Get a flu shot Always	Get a flu shot Not Applicable
Practice safe sex	Practice safe sex Never	Practice safe sex Sometimes	Practice safe sex Always	Practice safe sex Not Applicable
Take vitamins or supplements	Take vitamins or supplements Never	Take vitamins or supplements Sometimes	Take vitamins or supplements Always	Take vitamins or supplements Not Applicable
Get at least 7 hours of sleep	Get at least 7 hours of sleep Never	Get at least 7 hours of sleep Sometimes	Get at least 7 hours of sleep Always	Get at least 7 hours of sleep Not Applicable
Effectively manage stress	Effectively manage stress Never	Effectively manage stress Sometimes	Effectively manage stress Always	Effectively manage stress Not Applicable
Feel satisfied with your life	Feel satisfied with your life Never	Feel satisfied with your life Sometimes	Feel satisfied with your life Always	Feel satisfied with your life Not Applicable
Participate in 30 minutes of physical activity/exercise daily	Participate in 30 minutes of physical activity/exercise daily Never	Participate in 30 minutes of physical activity/exercise daily Sometimes	Participate in 30 minutes of physical activity/exercise daily Always	Participate in 30 minutes of physical activity/exercise daily Not Applicable

17. How much do you agree with the following?

	Never	Sometimes	Always
I am exposed to second hand smoke at work or home.	*How much do you agree with the following? I am exposed to second hand smoke at work or home. Never	I am exposed to second hand smoke at work or home. Sometimes	I am exposed to second hand smoke at work or home. Always
I perform self -exams for cancer (breast or testicular) monthly.	I perform self -exams for cancer (breast or testicular) monthly. Never	I perform self -exams for cancer (breast or testicular) monthly. Sometimes	I perform self -exams for cancer (breast or testicular) monthly. Always
I eat 5 servings of fruits and vegetables each day.	I eat 5 servings of fruits and vegetables each day. Never	I eat 5 servings of fruits and vegetables each day. Sometimes	I eat 5 servings of fruits and vegetables each day. Always
I eat fast food more than once a week.	I eat fast food more than once a week. Never	I eat fast food more than once a week. Sometimes	I eat fast food more than once a week. Always
I drink more than 3 alcoholic drinks each day.	I drink more than 3 alcoholic drinks each day. Never	I drink more than 3 alcoholic drinks each day. Sometimes	I drink more than 3 alcoholic drinks each day. Always

18. Do you have any ideas that could improve the health problems in your community?

Do you have any ideas that could improve the health problems in your community?

Thank you for completing our survey! We hope to work with you on building healthier communities. For more information, you can log onto www.umms.org