This survey is completely anonymous, ensuring confidentiality and encouraging honest responses, thus enabling an understanding of the community's health landscape.
 
Filling out this community health needs assessment survey is crucial for understanding and addressing the health concerns of our community effectively.
 
By participating in this survey, individuals provide valuable insights into the health issues, priorities, and unmet needs within the community. This information helps healthcare providers and organizations allocate resources efficiently to improve public health outcomes.
 
This survey plays a vital role in shaping a healthier future for everyone in Hancock County and the surrounding region.

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* 1. What ZIP code do you reside in?

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* 2. Gender?

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* 3. What is your race?

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* 4. What is your highest level of education?

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* 5. How would you describe your housing situation? (check only one)

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* 6. What was the combined household income last year? (check only one)

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* 7. Please answer all three questions for each person in your household.
First, indicate the ages of each household member.
Second, mark what best describes each person's health condition.
Third, mark those who are disabled.

  17 years and under 18-44 years 45-64 years 65+ Excellent Condition Good Condition Poor Condition Yes Disabled Not Disabled
Yourself
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10

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* 8. When was your last visit to the primary healthcare provider for a routine check-up? (A routine check-up is a general visit, not for a specific injury, illness, or condition).

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* 9. If your last visit was more than two years ago, is it because you

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* 10. Have you or anyone in your household had any difficulty finding a specialist within the past two years? 

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* 11. If yes to Question 10, why were you unable to visit the specialist when you needed one?

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* 12. Which of these healthcare services do you use?

  Yes No
Holistic/Integrative Services
Dental Services
Mental/Behavioral Health Services
Substance Misuse Services
Vision Services
Health Coaching Services
Massage Therapy Services
Acupuncture Services
Chiropractic Services
Sexual Health and Contraceptive
Dietitian Services

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* 13. If you answered NO to question 12, are you aware of one you can use?

  Yes No
Holistic/Integrative Services
Dental Services
Mental/Behavioral Health Services
Substance Misuse Services
Vision Services
Health Coaching Services
Massage Therapy Services
Acupuncture Services
Chiropractor Services
Sexual Health and Contraceptive
Dietitian Services

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* 14. About how long has it been since you had the following tests/screening done?

  Within the past year Within the past 2 years Within the past 5 years 5 years or more Never Not Applicable
Blood Cholesterol
Colon Cancer
Diabetes
Mammogram
Breast Exam by a Medical Provider
Pap Smear
Prostate Cancer
Lung Cancer
Skin Cancer Screening

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* 15. I am being treated for? (check all that apply)

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* 16. Is a child in your household (age 18 or younger) being treated for any of the following? (check all that apply)

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* 17. Do you have a primary healthcare provider?

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* 18. If you have a primary healthcare provider, where is he/she located?

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* 19. What hospital do you use for emergency services?

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* 20. What hospital do you use for surgical services?

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* 21. How do you choose a hospital to receive care?

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* 22. When you get sick where do you go for care?

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* 23. How many times during the past 12 months have you or any household member used a hospital emergency room? (check only one)

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* 24. If you or a household member used a hospital emergency room in the past 12 months, was it because of:

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* 25. In your opinion, what are the five (5) most pressing health problems in your community? (check only 5)

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* 26. What do you believe are the top three (3) issues missing in your community? (Please select only 3)

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* 27. In your opinion, what five types of health education services are most needed in your community? (check only 5)

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* 28. What health or community services would you like to see provided?

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* 29. Is there anything else you would like to share about your health goals?

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* 30. How many times in a typical week are you physically active? (example: walking, running, swimming, exercise, golf... etc...

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* 31. Do you smoke cigarettes, vape (electronic cigarettes), or chew tobacco?

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* 32. If you answered yes to question 31, are you interested in quitting?

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* 33. Does anyone in your household use the following? (check all that apply)

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* 34. How many members in your household are covered by the following health insurance options?

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* 35. Do any of these insurance policies provide dental coverage?

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* 36. Do any of these insurance policies provide vision coverage?

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* 37. Do any of these insurances pay for prescription drugs?

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* 38. In the last year, was there a time you needed a prescription medication but you could not get it?

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* 39. If you were unable to get your prescription medication, why not?

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