2021 Community Health Needs Assessment--Indian Stream Health Center

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* 1. Where do you live?

Coos County, NH

Essex County, VT

Maine

Canada

Other

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* 2. In the past two years, did you or a family member want or need any of these services?

Annual check up in doctor's office (routine check up, screenings, etc.)

Cancer screening

Emergency room visit

Mental Health Counseling

Visit to local pharmacy for prescription

Other (please specify)

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* 3. In the past two years, have you or a family member experienced difficulty in accessing any of the services listed above?

Yes

Other (please specify)

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* 4. What is your age group?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 5. What is the highest level of education you have completed?

Graduated from high school

Graduated from college

Completed graduate school

Other (please specify)

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* 6. What is your household income?

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

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* 7. To you and/or your family, please list the three most important factors for a healthy community in the comment box. (examples could be: access to primary care and services, cost/affordability, technology, access to specialty care, access to diagnostic services/lab/xray, health education/prevention, access to healthy foods/exercise, transportation to medical appointments)

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* 8. To you and your family, please list the top three health challenges (barriers to care) in your community in the comment box.

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* 9. For yourself, what are your personal TOP three health challenges? Please list in comment box.

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* 10. How would you rate the overall health of your community?

Excellent

Good

Average

Poor

Other (please specify)

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* 11. How would you rate your own personal health?

Excellent

Good

Average

Poor

Other (please specify)

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* 12. How do you pay for your/your family's healthcare?

Private insurance from my employer

Medicare

Medicaid

Self-insured

Self pay

Other

Other (please specify)

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* 13. Do you have a primary care provider (i.e., Doctor, Physician Assistant, Nurse Practitioner) that you see for routine health needs?

Yes

Other (please specify)

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* 14. When it comes to your primary care provider and the care and services you receive, please check all areas that are most important to you. Your additional comments are welcome in the comment section.

Providers are skilled and caring

My provider's office staff is caring, competent and easy to work with

My provider's office is a pleasant setting

Because my provider is in a medical home environment, I have quick access to other services

My provider's office has other services onsite, including behavorial health and a full service pharamacy

Other (please specify)

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* 15. Thank you very much for your time in filling out this survey. Please feel free to list all and any additional suggestions in the comment section.