North Idaho's Community Health Assessment Please answer each question to the best of your ability, based on your personal experience. Question Title * 1. How would you rate your county as a “healthy community?" Healthy Very Healthy Somewhat Healthy Unhealthy Very Unhealthy OK Question Title * 2. In your opinion, what are the THREE most significant health problems in your county? (Problems that have the greatest impact on overall community health) Aging population Alcohol Abuse Cancer Child abuse/neglect Dental problems Diabetes Domestic violence Drug Abuse Fire-arm related injuries Heart disease and stroke High blood pressure HIV/AIDS Homicide Infant death Infectious disease (i.e. hepatitis, pertussis, TB, etc.) Mental health Motor vehicle crash injuries Obesity Respiratory/lung disease Sexual assault Sexually transmitted disease Suicide Teenage pregnancy Other (please specify) OK Question Title * 3. In your opinion, what are the THREE most significant health behaviors in your county? (Behaviors that have the greatest impact on overall community health) Alcohol abuse Dropping out of school Drug abuse Eating unhealthy foods Not exercising Not using birth control Not using seat belts/child safety seats Overeating Racism Tobacco use Unsafe sex Not getting “Immunizations” or “shots” to prevent disease Other (please specify) OK Question Title * 4. How would you rate your individual health? Excellent Very Good Good Fair Poor Don’t know/not sure OK Question Title * 5. Please select the top THREE health challenges you currently face. Alcohol abuse Cancer Diabetes Drug addiction Heart disease High blood pressure High cost of health care Joint pain or back pain Lung disease Mental health No health insurance Overweight/obesity Poor oral health Stroke I do not have any health-related challenges Other (please specify) OK Question Title * 6. During the past 30 days, how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? 0 days 15 days 30 days Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 7. In regards to your physical health, including physical illness and injury, how many days during the past 30 days was your physical health NOT good? 0 days 15 days 30 days Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 8. In regards to your mental health, including stress, depression, and problems with emotions, how many days during the past 30 days was your mental health NOT good? 0 days 15 days 30 days Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 9. During the past 12 months, what has been the biggest source of stress in your life? OK Question Title * 10. In the past 12 months, did you receive counseling or treatment for mental health concerns? Yes No Don’t know/not sure OK Question Title * 11. If you felt you needed mental health treatment or counseling but did not receive it, what was the primary obstacle preventing you from receiving care? I could not afford the cost I was concerned that getting mental health treatment or counseling might cause my neighbors, or community to have a negative opinion of me I was concerned that getting mental health treatment or counseling might have a negative effect on my job My health insurance does not cover any mental health treatment or counseling My health insurance does not pay enough for mental health treatment or counseling I did not know where to go to get services I was concerned that the information I gave my counselor might not be kept confidential I was concerned that I might be admitted to a psychiatric hospital or might have to take medicine I did not need treatment Other (please specify) OK Question Title * 12. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. Less than 12 months 1-2 years 2-5 years 5 or more years Don’t know/not sure OK Question Title * 13. How many of your permanent teeth have been removed because of tooth decay or gum disease? (This includes teeth lost to infection, but not teeth lost for other reasons, such as injury or orthodontics. ) None 1-5 6 or more All Don’t know/not sure OK Question Title * 14. During the past 12 months, how often did you have to cut meal sizes or skip meals due to insufficient money for food? Once a week Once a month A few times a year Once a year Never Other (please specify) OK Question Title * 15. Do you currently have any kind of healthcare coverage, including health insurance, prepaid plans (HMOs), government plans (Medicaid/Medicare), or Indian Health Services? Yes No Don’t know/not sure Refused OK Question Title * 16. Of the following support services, which one do YOU most need, that you are not currently getting? Classes about giving care, such as giving medications Help in getting access to services Support groups Individual counseling to help cope with giving care Respite care I don’t need any of these support service OK Question Title * 17. During the past 30 days, have you participated in any physical activities or exercise such as running, biking, calisthenics, or walking for exercise? Yes No Don’t know/not sure OK Question Title * 18. If there was a time in the past 12 months when you needed to see a doctor but could not, what obstacles prevented you from receiving care? Select all that apply. I did not need to see the doctor Did not have difficulty accessing health care I could not afford the cost Lack of time No doctor appointments available Lack of transportation Did not know where to seek care Lack of employer flexibility Don’t know/not sure Other (please specify) OK Question Title * 19. How often do you currently use tobacco products, such as chewing tobacco, cigarettes, snuff, or snus? Every day Most days Rarely Not at all Don’t know/not sure OK Question Title * 20. How often do you currently use e-cigarettes or other electronic “vaping” products? Every day Most days Rarely Not at all Don’t know/not sure OK Question Title * 21. During the past 30 days, how many days did you have at least one alcoholic beverage such as beer, wine, a malt beverage, or liquor? 0 days 15 days 30 days Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 22. In the past seven days, how many days did you exercise for at least 30 minutes? 6-7 days 4-5 days 1-3 days None OK Question Title * 23. During the past 30 days, how many times per day and per week did you eat fruit? Count fresh, frozen or canned fruit, NOT juice. 0 1-2 3-4 5+ Unknown/ Not sure Times per day Times per day 0 Times per day 1-2 Times per day 3-4 Times per day 5+ Times per day Unknown/ Not sure Times per week Times per week 0 Times per week 1-2 Times per week 3-4 Times per week 5+ Times per week Unknown/ Not sure OK Question Title * 24. If you did not eat fruit in the past 30 days, please explain why. If you did, please skip to the next question. OK Question Title * 25. During the past 30 days, how many times per day, and per week, did you eat green vegetables such as broccoli romaine, chard, collard greens or spinach? 0 1-2 3-4 5+ Unknown/ Not sure Times per day Times per day 0 Times per day 1-2 Times per day 3-4 Times per day 5+ Times per day Unknown/ Not sure Times per week Times per week 0 Times per week 1-2 Times per week 3-4 Times per week 5+ Times per week Unknown/ Not sure OK Question Title * 26. If you did not eat greens in the past 30 days, please explain why. If you did, please skip to the next question. OK Question Title * 27. In the past 12 months, how often did alcohol use, by you or another member of your household, cause stress, conflict, or anxiety for you? Once a week Once a month A few times a year Once a year Never OK Question Title * 28. Do you currently have enough non-perishable food, water, medical supplies and other supplies (e.g. flashlights, radio, batteries, etc.) at your home to be able to stay in place during an emergency or disaster for up to 3 days? Yes No I don’t know OK Question Title * 29. Do you have an established emergency or disaster plan (Actions you would take, including how you would communicate with family or friends during an emergency) for you and your family? Yes No I don’t know OK Question Title * 30. What is your home zip code? OK Question Title * 31. Indicate your gender. Male Female Transgender OK Question Title * 32. Indicate your race/ethnicity. Asian or Pacific Islander Black/African American Hispanic/Latino American Indian/Native American White/Caucasian Other (please specify) OK Question Title * 33. Select the category that includes your age. Under 18 18-24 25-34 35-44 45-54 55-64 65 or above OK Question Title * 34. What is your marital status? Married Living together, unmarried Divorced Separated Widowed Never been married OK Question Title * 35. What is your highest level of education? K-8th grade Some high school High school degree Technical school Some college Associate’s degree Bachelor’s degree Graduate school OK Question Title * 36. In 2016, what was your annual household income from all sources? Less than $10,000 $10,000 to under $25,000 $25,000 to under $50,000 $50,000 to under $75,000 $75,000 to under $100,000 $100,000 or more Prefer not to say OK Question Title * 37. How many children live in your household? If none, write 0. OK Question Title * 38. Would you like to provide us with your name and contact information to be entered into a drawing for a Kindle Fire?***Your survey answers are not part of a HIPAA protected medical record, however your contact information will be kept confidential.*** Yes No OK Question Title * 39. THIS IS VOLUNTARY. Your survey answers are not part of a HIPAA protected medical record, however any and all contact information will be kept confidential. Please provide us with... Name: Email: OK DONE