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* 1. North Country Hospital wants to hear from you!  Please tell us how important the following issues are to the health of people living in Orleans & Northern Essex counties.  All comments are confidential.

1. Vision needs

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* 2. Dental needs

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* 3. Physical activity/exercise (at least 150 minutes per week)

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* 4. Healthy eating habits such as eating fruits & vegetables daily

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* 5. Lack of affordable healthy food choices

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* 6. Mental heath problems such as anxiety & depression

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* 7. Suicide or attempted suicide

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* 8. Violence in the home

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* 9. Rape and/or sexual assault

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* 10. Safety/Crime

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* 11. Housing situations (such as bed bugs, mold, etc.)

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* 12. Homelessness

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* 13. Lack of education

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* 14. Lack of jobs

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* 15. Poverty

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* 16. Infections like pneumonia, flu and/or hepatitis that can be prevented by immunizations

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* 17. Being overweight-adults

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* 18. Tobacco use among adults

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* 19. Alcohol abuse among adults

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* 20. Abuse of prescription medication among adults

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* 21. Use of street drugs such as heroin, cocaine, etc. among adults

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* 22. Infant or childhood diseases that can be prevented by immunization

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* 23. Child abuse or neglect

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* 24. Being overweight-Youth

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* 25. Tobacco use among youth

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* 26. Alcohol use among youth

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* 27. Use of street drugs such as heroin, cocaine, etc. among youth

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* 28. Use this space to enter any other issues that you believe impact community's health:

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* 29. The following are healthcare services and/or community resources.  Please tell us how they meet the needs in our community.

Older Vermonters: Housing

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* 30. Older Vermonters: Meal programs

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* 31. Older Vermonters: Home care

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* 32. Older Vermonters: Nursing Homes

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* 33. Older Vermonters: Adult day care

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* 34. Disability assistance

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* 35. Cancer Care: Screening/testing

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* 36. Cancer Care: Treatment

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* 37. Dental care

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* 38. Services specializing in eye care

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* 39. Services for women who are pregnant

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* 40. Services for new moms/dads and babies

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* 41. Support services for people who need end of life care (hospice)

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* 42. Resources that reduce poverty

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* 43. Services for people of any age to remain in their home

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* 44. Legal services

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* 45. Services for people who have heart and/or breathing problems and/or diabetes

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* 46. Services to quit tobacco use

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* 47. Childcare

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* 48. Services for people experiencing violence in the home or sexual assault

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* 49. Addiction support services

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* 50. Mental health care when you need it

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* 51. Alcohol treatment when you need it

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* 52. Drug treatment when you need it

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* 53. Medical care when you need it without going to the Emergency Department

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* 54. Services for adults wanting a high school education

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* 55. Access/affordability for education after high school

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* 56. Services that encourage healthy eating, such as farmers markets, etc.

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* 57. Affordable exercise/fitness programs

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* 58. Recreation activities, such as swimming, hiking, etc.

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* 59. Transportation for medical appointments

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* 60. Transportation for other reasons

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* 61. Safe walking and/or biking paths and sidewalks

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* 62. Use this space to enter in services that you believe are not available but are needed.

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* 63. Please tell us about yourself.

In the last 18 months have you had a visit with any of the following?

An eye doctor

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* 64. A dental provider

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* 65. A doctor/medical provider

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* 66. A mental health provider

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* 67. A substance use provider

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* 68. Highest level of education:

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* 69. Age:

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* 70. What is your gender?

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* 71. Please select the town you live in:

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* 72. Are you employed?

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* 73. My household yearly income is:

This Community Health Survey was designed with help from representatives of local organizations including, the Vermont Department of Health, Orleans Essex VNA & Hospice, Northeast Kingdom Council on Aging, Northeast Kingdom Community Action, Northeast Kingdom Learning Services, North Country Hospital and Northeast Kingdom Human Services.

Thank you for your participation!

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