Macon County Community Needs Assessment Survey

2. Which category below includes your age?

Which category below includes your age? 18-24 25-34 34-44	45-54 55-64 over 65
If you are under age 18, you no longer have to continue survey.

3. How many children age 17 or younger live in your household?

How many children age 17 or younger live in your household?

4. Which ethnic group do you most identify with ?

Which ethnic group do you most identify with ? White

Black or African-American

American Indian or Alaskan Native

Asian

Hispanic

From multiple races

5. Are you now married, widowed, divorced, separated, or never married?

Are you now married, widowed, divorced, separated, or never married? Married

Widowed

Divorced

Separated

Never married

6. What is the highest level of school you have completed or the highest degree you have received?

What is the highest level of school you have completed or the highest degree you have received? Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree	Associate degree Bachelor degree Graduate degree
Technical/Training School

7. What is your current household income?

What is your current household income? Less than 20,000

20,000 to 29,999

30,000 to 49,999

50,000 to 59,999

60,000 or above

8. Which of the following best describes your health insurance status?

Which of the following best describes your health insurance status? Insured through your employer

Insured through your spouse's employer

Insured through Medicare

Insured through Medicaid

Insured through VA, Champus, or other military plan

Insured through a plan your purchased on your own or Cobra

No insurance

9. Where did you get this survey?

Where did you get this survey? Church Community Meeting Mail	Newspaper Personal Contact Work Place	Website/E-Mail Dr's office Civic Club
Other (please specify)

10. In your opinion,what do most people die from in your community? (check only one)

In your opinion,what do most people die from in your community? (check only one) Asthma/Lung Disease Cancer Diabetes Suicide	HIV/AIDS Heart Disease Old Age Stroke.Cerebrovascular Disease	Homicide/ Violence Motor Vehicle Deaths Infectious Disease
Other (please specify)

11. If you get sick,where would you go first? (ie: flu,upset stomach,blood pressure,diabetes)

If you get sick,where would you go first? (ie: flu,upset stomach,blood pressure,diabetes) Emergency Room Health Department Local Health Care Clinic	Physician ( in town) Physician (out of town)
Other (please specify)

12. If you get sick,where do you go if you need hospital care? (check only one)

If you get sick,where do you go if you need hospital care? (check only one) Macon County General Hospital

Macon County General Hospital Emergency

Trousdale Medical Center

Riverview Regional Medical Center

University Medical Center

Sumner Regional Medical Center

Hendersonville Medical Center

Monroe Medical Center

The Medical Center, Allen County,KY

Nashville Area Hospitals

13. In your opinion,what is the biggest health issue of concern in your community?
(select up to 3 )

In your opinion,what is the biggest health issue of concern in your community? (select up to 3 ) Asthma/Lung Disease Cancer Diabetes Heart Disease Stroke	Child Abuse Dental Health Drug/Alcohol Abuse Violence Depression/Anxiety	Obesity Teen Pregnancy Tobacco Use Accidental Injuries Suicide
Other (please specify)

14. In your opinion,what do you think is the main reason that keeps people in your community from seeking medical treatment? (select only one)

In your opinion,what do you think is the main reason that keeps people in your community from seeking medical treatment? (select only one) Cultural/Health Beliefs Fear ( not ready too face the problem) Health Services too far away Lack of insurance/ unable not too pay	Could not get off from work Lack of knowledge/understanding the need Didn't think it was important Transportation	No timely or available appointments In office wait time
Other (please specify)

15. How do you rate your own health?

How do you rate your own health? Excellent

Very Good

Good

Fair

Poor

Don't Know/Not Sure

16. Which of the following health related behaviors describe you? (select all that apply)

Which of the following health related behaviors describe you? (select all that apply) Alcohol Abuse/Overuse Being Overweight Lack of exercise Poor eating habits Not getting shots to prevent disease Not getting regular check ups/screenings	Tobacco use (smoke,chew,dip) Not using birth control/protection Not using seat belts/ child safety seats Misuse of /prescription or illegal substance Lack of stress management
Other (please specify)

17. Does anyone in your household use tobacco products? ( smoke,chew,dip)

Does anyone in your household use tobacco products? ( smoke,chew,dip) Yes

18. Where do you and your family get most of your health information? (select all that apply)

Where do you and your family get most of your health information? (select all that apply) Health Education Program Family & Friends Internet Doctor/Health Professional	TV Hospital Newspaper/Magazines Library	Health Department Radio School Health Program Support Groups
Other (please specify)

19. Where do you get your information on community news/events?

Where do you get your information on community news/events? NCTC Information Chan Schools	Radio Local Newspaper	Flyers/Poster Social Network
Other (please specify)

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Macon County Community Needs Assessment
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