Please fill out this survey to help us assess the health needs of Hancock County, Illinois.

* 1. What is your ZIP code?

* 2. Gender?

* 3. What is your race?

* 4. What are the ages of the people who live in your household?

  0-35 months 3-5 years 6-12 years 13-17 years 18-24 years 25-44 years 45-54 years 55-64 years 65+
Yourself
Person 2
Person 3
Person 4
Person 5
Person 6

* 5. About how long have you lived in the area?

* 6. Including yourself, how many members of your household are disabled?

* 7. Including yourself, how many adults (age 18 or older) in your household are in fair-to-poor health?

* 8. Is any child (age 17 or younger) in your household in fair-to- poor health?

* 9. Are you or any household member a PRIMARY caregiver for an aged, disabled or chronically ill person? (including a parent, spouse or other relative)

* 10. How long has it been since you last visited a doctor for a routine check-up? (A routine check-up is a general visit, not a visit for a specific injury, illness or condition).

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

* 12. If you or a household member have a health care need:

  Yes No
Are you aware of a doctor/healthcare provider you can go to?
Are you aware of a dentist you can go to?
Are you aware of a mental health specialist you can go to?
Are you aware of a substance abuse counselor you can go to?
Are you aware of an eye doctor you can go to?

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

* 14. If you or a household member used a hospital emergency room in the past 12 months, was it due to:

* 15. Have you or anyone in your household had any difficulty finding a primary doctor/medical provider or specialist within the past two years?

* 16. If yes to Question 15, briefly, why would you say you had trouble finding a primary doctor/medical provider?

* 17. In response to Question 15, why were you unable to visit the specialist when you needed one?

* 18. About how long has it been since you had your blood cholesterol level checked?

* 19. When was your blood checked last for diabetes?

* 20. When was your last exam or screening for colon cancer?

* 21. When was your last mammogram?

* 22. When was your last breast exam by a doctor or nurse?

* 23. When was your last Pap Smear?

* 24. When was your last exam or screening for prostate cancer?

* 25. What are the most pressing health problems in your community? (Check 5)

* 26. Please check the types of health education services most needed in your community? (check 5)

* 27. What health or community services would you like to see Memorial Hospital provide that currently are not available?

* 28. What ideas or suggestions do you have for improving the overall health of the area?

* 29. During the past 12 months, have you received a flu shot?

* 30. During the past month have you participated in any physical activities or exercise, such as running, walking, golf, etc.?

* 31. If yes, how many times a week do you take part in this activity?

* 32. How many minutes or hours do you usually keep at this activity?

* 33. Do you smoke cigarettes, chew tobacco or use electronic cigarettes?

* 34. If yes, how much on an average day?

* 35. If yes, are you interested in stopping?

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

* 37. Has a child in your household (age 17 or younger) been told they have one of the following conditions? (check all that apply)

* 38. Has a child in your household (age 17 or younger) used the following? (check all that apply)

* 39. What is the highest level of education?

* 40. Including yourself, how many adults in your household are retired?

* 41. Including yourself, how many adults (18+) in your household are employed full time, year-round?

* 42. How many household members are currently covered by health insurance?

* 43. If you or members of your household have health insurance coverage, how is it obtained? (check all that apply)

* 44. Do any of these insurance policies provide dental or vision coverage?

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

* 46. What hospital do you use?

* 47. Why?

* 48. Counting all income sources from everyone in your household, what was the combined household income last year? (check only one)

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

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