HCHC Survey 2016 Hillsdale Community Health Assessment Survey Question Title * 1. Are you: Male Female Question Title * 2. Are you a Hillsdale County resident? Yes No Question Title * 3. What is your Age? 18 to 20 years 21 to 30 years 31 to 40 years 41 to 50 years 51 to 60 years 61 to 64 years 65 to 75 years over 75 years Question Title * 4. How would you best describe your race? White African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Two or more races Question Title * 5. How would you best describe your ethnic background? Hispanic Non-Hispanic Question Title * 6. Do you currently have health insurance? Yes No Question Title * 7. If you have health insurance, is it through: Your employer, even if you pay part of the cost A private plan where you pay all of the cost (non-subsidized) A private plan where you pay some of the cost (government subsidized) Medicaid The Branch-Hillsdale-St. Joseph County Health Plan Medicare only Medicare with a supplemental plan Question Title * 8. If you have health insurance, does your plan cover: Prescriptions Dental work Question Title * 9. Do you have a regular doctor (personal physician)? Yes No Question Title * 10. If you do have a regular doctor, is your doctor in Hillsdale County? Yes No Question Title * 11. If you have a regular doctor, how often do you normally visit your doctor each year? Once Twice Four times Monthly More than monthly Question Title * 12. What best describes your employment situation? In school/too young to be employed Employed by a company full time Employed by a company part time or seasonally Self-employed Homemaker Unemployed but seeking work Unemployed not seeking work On permanent disability Retired Question Title * 13. Are you a caregiver for any sick or aged person? Yes No Question Title * 14. If you are a caregiver, do you live with that person? Yes No Does not apply to me Question Title * 15. If you are a caregiver, how would you rate the healthcare service or support currently being received? Insufficient Adequate Good Excellent Not sure Does not apply to me Question Title * 16. What best describes your living situation? Living in your own home Renting a house or apartment Staying with relatives or others in their home Homeless Question Title * 17. What best describes your marital status? Single (never married) Single (divorced) Living with a significant other Married Married but separated Widowed Question Title * 18. How many children under age 18 live in your home? None One Two Three Four More than four How many if more than four? Question Title * 19. What is the highest grade you completed in school? Less than High School High School/GED certificate Trade School Some college (no degree) Associate degree from a junior college College degree (B.S/B.A. or equivalent) Advanced college degree Question Title * 20. If you need medical treatment (not counting accidents or a crisis such as a heart attack), where do you normally go? Hospital ER Urgent Care Health Department St. Peter's Clinic in Hillsdale Clinic outside Hillsdale County Personal physician Other (please specify): Question Title * 21. Do you have: Yes No Don't know Arthritis Arthritis Yes Arthritis No Arthritis Don't know Asthma Asthma Yes Asthma No Asthma Don't know Cancer Cancer Yes Cancer No Cancer Don't know COPD COPD Yes COPD No COPD Don't know Diabetes Diabetes Yes Diabetes No Diabetes Don't know Fibromyalgia Fibromyalgia Yes Fibromyalgia No Fibromyalgia Don't know Heart Disease Heart Disease Yes Heart Disease No Heart Disease Don't know High Blood Pressure High Blood Pressure Yes High Blood Pressure No High Blood Pressure Don't know High Cholesterol High Cholesterol Yes High Cholesterol No High Cholesterol Don't know High or Low Thyroid High or Low Thyroid Yes High or Low Thyroid No High or Low Thyroid Don't know Lupus Lupus Yes Lupus No Lupus Don't know Migraines Migraines Yes Migraines No Migraines Don't know Other chronic disease Other chronic disease Yes Other chronic disease No Other chronic disease Don't know If another chronic disease, please specify: Question Title * 22. Do you currently smoke? Yes No Question Title * 23. Do you currently drink alcohol? Yes No Question Title * 24. If you currently drink alcohol, is it: Yes No More than one drink a day? More than one drink a day? Yes More than one drink a day? No More than three a day? More than three a day? Yes More than three a day? No Question Title * 25. Do you currently use drugs such as: Yes No Marijuana Marijuana Yes Marijuana No Cocaine Cocaine Yes Cocaine No Any illegal drug Any illegal drug Yes Any illegal drug No Question Title * 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 Misuse/abuse of prescription drugs Very Misuse/abuse of prescription drugs Moderately Misuse/abuse of prescription drugs Not at all Substance abuse among youth Substance abuse among youth Very Substance abuse among youth Moderately Substance abuse among youth Not at all Substance abuse among adults Substance abuse among adults Very Substance abuse among adults Moderately Substance abuse among adults Not at all Question Title * 27. Are you concerned about your weight? Yes No Question Title * 28. When you think about your weight, do you think you are? Underweight Overweight Average weight Obese Question Title * 29. In the past year, have you ever had: Yes No Trouble finding a doctor if you need one? Trouble finding a doctor if you need one? Yes Trouble finding a doctor if you need one? No A long wait to get a doctor appointment A long wait to get a doctor appointment Yes A long wait to get a doctor appointment No Trouble finding transportation to get to a doctor? Trouble finding transportation to get to a doctor? Yes Trouble finding transportation to get to a doctor? No Question Title * 30. How concerned are you, as a resident of Hillsdale County, about: Very Moderately Not at all The quality of healthcare available The quality of healthcare available Very The quality of healthcare available Moderately The quality of healthcare available Not at all The affordability of healthcare available The affordability of healthcare available Very The affordability of healthcare available Moderately The affordability of healthcare available Not at all Question Title * 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 General Practitioner No General Practitioner Yes in Hillsdale County General Practitioner Yes but outside Hillsdale County Chiropractor Chiropractor No Chiropractor Yes in Hillsdale County Chiropractor Yes but outside Hillsdale County Eye doctor Eye doctor No Eye doctor Yes in Hillsdale County Eye doctor Yes but outside Hillsdale County Psychologist/Psychiatrist Psychologist/Psychiatrist No Psychologist/Psychiatrist Yes in Hillsdale County Psychologist/Psychiatrist Yes but outside Hillsdale County Foot Doctor Foot Doctor No Foot Doctor Yes in Hillsdale County Foot Doctor Yes but outside Hillsdale County Hearing Specialist Hearing Specialist No Hearing Specialist Yes in Hillsdale County Hearing Specialist Yes but outside Hillsdale County Physical Therapist Physical Therapist No Physical Therapist Yes in Hillsdale County Physical Therapist Yes but outside Hillsdale County Dietician Dietician No Dietician Yes in Hillsdale County Dietician Yes but outside Hillsdale County Cardiologist Cardiologist No Cardiologist Yes in Hillsdale County Cardiologist Yes but outside Hillsdale County OB/GYN (if female) OB/GYN (if female) No OB/GYN (if female) Yes in Hillsdale County OB/GYN (if female) Yes but outside Hillsdale County Dentist/Orthodontist Dentist/Orthodontist No Dentist/Orthodontist Yes in Hillsdale County Dentist/Orthodontist Yes but outside Hillsdale County Neurologist Neurologist No Neurologist Yes in Hillsdale County Neurologist Yes but outside Hillsdale County Gastroenterologist Gastroenterologist No Gastroenterologist Yes in Hillsdale County Gastroenterologist Yes but outside Hillsdale County Question Title * 32. In the past year, have you: Yes No Not applicable Had a flu shot? Had a flu shot? Yes Had a flu shot? No Had a flu shot? Not applicable Had a pneumonia shot? Had a pneumonia shot? Yes Had a pneumonia shot? No Had a pneumonia shot? Not applicable Had a colonoscopy? Had a colonoscopy? Yes Had a colonoscopy? No Had a colonoscopy? Not applicable Been pregnant (if female) Been pregnant (if female) Yes Been pregnant (if female) No Been pregnant (if female) Not applicable Had a mammogram (if female) Had a mammogram (if female) Yes Had a mammogram (if female) No Had a mammogram (if female) Not applicable Had a Papp smear (if female) Had a Papp smear (if female) Yes Had a Papp smear (if female) No Had a Papp smear (if female) Not applicable Had a prostate screening (if male) Had a prostate screening (if male) Yes Had a prostate screening (if male) No Had a prostate screening (if male) Not applicable Question Title * 33. How many times have you been hospitalized in the past year? No time One time Two times More than two times Question Title * 34. If you were hospitalized in the past year, was it at the Hillsdale Hospital? Yes No Does not apply to me Question Title * 35. If you were hospitalized, but not in Hillsdale, then where? Question Title * 36. In the past year, have you ever felt: Yes No Depressed (very sad for more than one week) Depressed (very sad for more than one week) Yes Depressed (very sad for more than one week) No Suicidal Suicidal Yes Suicidal No Afraid of someone hurting you Afraid of someone hurting you Yes Afraid of someone hurting you No Afraid you would hurt someone close to you Afraid you would hurt someone close to you Yes Afraid you would hurt someone close to you No Question Title * 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? Yes No Question Title * 38. How concerned are you here in Hillsdale County with Environmental issues such as: Very Moderately Not at all Water pollution Water pollution Very Water pollution Moderately Water pollution Not at all Air pollution Air pollution Very Air pollution Moderately Air pollution Not at all Radon Radon Very Radon Moderately Radon Not at all Question Title * 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 in natural disasters like storms Very Public safety in natural disasters like storms Moderately Public safety in natural disasters like storms Not at all Public safety due to terrorism Public safety due to terrorism Very Public safety due to terrorism Moderately Public safety due to terrorism Not at all Crime Crime Very Crime Moderately Crime Not at all Domestic violence Domestic violence Very Domestic violence Moderately Domestic violence Not at all Question Title * 40. How concerned are you here in Hillsdale County with Social issues such as: Very Moderately Not at all People living in poverty People living in poverty Very People living in poverty Moderately People living in poverty Not at all Affordable housing Affordable housing Very Affordable housing Moderately Affordable housing Not at all Teen pregnancy Teen pregnancy Very Teen pregnancy Moderately Teen pregnancy Not at all Employment opportunities Employment opportunities Very Employment opportunities Moderately Employment opportunities Not at all Thank you for taking time to participate in the Hillsdale Community Health Assessment Survey on behalf of the Hillsdale Community Health Center. Done