Hillsdale Community Health Assessment Survey

* 1. Are you:

* 2. Are you a Hillsdale County resident?

* 3. What is your Age?

* 4. How would you best describe your race?

* 5. How would you best describe your ethnic background?

* 6. Do you currently have health insurance?

* 7. If you have health insurance, is it through:

* 8. If you have health insurance, does your plan cover:

* 9. Do you have a regular doctor (personal physician)?

* 10. If you do have a  regular doctor, is your doctor in Hillsdale County?

* 11. If you have a regular doctor, how often do you normally visit your doctor each year?

* 12. What best describes your employment situation?

* 13. Are you a caregiver for any sick or aged person?

* 14. If you are a caregiver, do you live with that person?

* 15. If you are a caregiver, how would you rate the healthcare service or support currently being
received?

* 16. What best describes your living situation?

* 17. What best describes your marital status?

* 18. How many children under age 18 live in your home?

* 19. What is the highest grade you completed in school?

* 20. If you need medical treatment (not counting accidents or a crisis such as a heart attack), where do you normally go?

* 21. Do you have:

  Yes No Don't know
Arthritis
Asthma
Cancer
COPD
Diabetes
Fibromyalgia
Heart Disease
High Blood Pressure
High Cholesterol
High or Low Thyroid
Lupus
Migraines
Other chronic disease

* 22. Do you currently smoke?

* 23. Do you currently drink alcohol?

* 24. If you currently drink alcohol, is it:

  Yes No
More than one drink a day?
More than three a day?

* 25. Do you currently use drugs such as:

  Yes No
Marijuana
Cocaine
Any illegal drug

* 26. How concerned are you here in Hillsdale County with Substance Abuse issues, such as:

  Very Moderately Not at all
Misuse/abuse of prescription drugs
Substance abuse among youth
Substance abuse among adults

* 27. Are you concerned about your weight?

* 28. When you think about your weight, do you think you are?

* 29. In the past year, have you ever had:

  Yes No
Trouble finding a doctor if you need one?
A long wait to get a doctor appointment
Trouble finding transportation to get to a doctor?

* 30. How concerned are you, as a resident of Hillsdale County, about:

  Very Moderately Not at all
The quality of healthcare available
The affordability of healthcare available

* 31. In the past year, have you ever used any of the following services and, if so, was it in Hillsdale County?

  No Yes in Hillsdale County Yes but outside Hillsdale County
General Practitioner
Chiropractor
Eye doctor
Psychologist/Psychiatrist
Foot Doctor
Hearing Specialist
Physical Therapist
Dietician
Cardiologist
OB/GYN (if female)
Dentist/Orthodontist
Neurologist
Gastroenterologist

* 32. In the past year, have you:

  Yes No Not applicable
Had a flu shot?
Had a pneumonia shot?
Had a colonoscopy?
Been pregnant (if female)
Had a mammogram (if female)
Had a Papp smear (if female)
Had a prostate screening (if male)

* 33. How many times have you been hospitalized in the past year?

* 34. If you were hospitalized in the past year, was it at the Hillsdale Hospital?

* 35. If you were hospitalized, but not in Hillsdale, then where?

* 36. In the past year, have you ever felt:

  Yes No
Depressed (very sad for more than one week)
Suicidal
Afraid of someone hurting you
Afraid you would hurt someone close to you

* 37. In the past year, have you ever gone without food or utilities to pay for prescription drugs, or gone without a prescription drug to pay for food or utilities?

* 38. How concerned are you here in Hillsdale County with Environmental issues such as:

  Very Moderately Not at all
Water pollution
Air pollution
Radon

* 39. How concerned are you here in Hillsdale County with Safety issues such as:

  Very Moderately Not at all
Public safety in natural disasters like storms
Public safety due to terrorism
Crime
Domestic violence

* 40. How concerned are you here in Hillsdale County with Social issues such as:

  Very Moderately Not at all
People living in poverty
Affordable housing
Teen pregnancy
Employment opportunities
Thank you for taking time to participate in the Hillsdale Community Health Assessment Survey on behalf of the Hillsdale Community Health Center.

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