DHLC Community Health Needs Assessment Survey
Thank you for participating in Deborah Heart and Lung Center's Community Health Needs Assessment Survey. As community members we value your opinion.
1
. In the following list, please check the top three health issues you think affect the residents of your community.
In the following list, please check the top three health issues you think affect the residents of your community.
Aging problems
Adult Asthma
Youth Asthma
Cancer
Adult Diabetes
Youth Diabetes
Adult Heart Disease
Youth Heart Disease
High blood pressure
High cholesterol
HIV/AIDS
Infectious Disease (TB, Hepatitis, etc.)
Lung Cancer
Mental health issues
Adult Obesity
Childhood Obesity
Respiratory/lung disease
Sexually Transmitted Disease (STD's)
Stroke
Adult Substance Abuse
Youth Substance Abuse
Adult Tobacco Use
Youth Tobacco Use
Other (please specify)
2
. Do you think residents in your community have difficulty getting the medical services they need
Do you think residents in your community have difficulty getting the medical services they need
Yes
No
3
. If you answered YES in 2 please check the reason(s) why you think community residents have difficulty getting medical services they need
If you answered YES in 2 please check the reason(s) why you think community residents have difficulty getting medical services they need
Afriad of Doctors
Inability to pay
No appointment was available
No access for people with disabilities
No insurance
No prescription plan
No transportation
No childcare
Language barriers
Available appointments are not convenient
Underinsured
Other (please specify)
4
. Do you currently have health insurance, or not?
Do you currently have health insurance, or not?
Yes, I do
No, I do not
5
. Do You Have a Doctor
Do You Have a Doctor
Yes
No
6
. What Hospital Do You Use?
What Hospital Do You Use?
7
. Thank you for your participation!
The following information is for this Survey Only and will not be shared or made public
Thank you for your participation! The following information is for this Survey Only and will not be shared or made public
Name
Address
City
State
Zip Code
Phone Number
e-mail
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