Community Health Needs Assessment Question Title * 1. What is your living situation today? I have a steady place to live I have a place to live today, but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) Question Title * 2. Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY Pests such as bugs, ants, or mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks None of the above FoodSome people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months. Question Title * 3. Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true Sometimes true Never true Question Title * 4. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. Often true Sometimes true Never true Transportation Question Title * 5. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? Yes No Utilities Question Title * 6. In the past 12 months has the electric, gas, oil or water company threatened to shut off services to your home? Yes No Already shut off Safety Because violence and abuse happens to a lot of people and affects their health we are asking the following questions. Question Title * 7. How often does anyone, including family and friends, physically hurt you? Never Rarely Sometimes Fairly often Frequently Question Title * 8. How often does anyone, including family and friends, insult or talk down to you? Never Rarely Sometimes Fairly often Frequently Question Title * 9. How often does anyone, including family and friends, threaten you with harm? Never Rarely Sometimes Fairly often Frequently Question Title * 10. How often does anyone, including family and friends, scream or curse at you? Never Rarely Sometimes Fairly often Frequently Financial Strain Question Title * 11. How hard is it for you to pay for the very basics like, food, housing, medical care, and heating? Would you say it is: Very hard Somewhat hard Not hard at all Employment Question Title * 12. Do you want help finding or keeping work or a job? Yes, help finding work Yes, help keeping work I do not need or want help Family and Community Support Question Title * 13. If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need? I don't need any help I get all the help I need I could use a little more help I need a lot more help Question Title * 14. How often do you feel lonely or isolated from those around you? Never Rarely Sometimes Often Always Education Question Title * 15. Do you speak a language other than English at home? Yes No Question Title * 16. Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent? Yes No Physical Activity Question Title * 17. In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)? 0 1 2 3 4 5 6 7 Question Title * 18. On average, how many minutes did you usually spend exercising at this level on one of those days? 0 10 20 30 40 50 60 90 120 150 or greater Substance UseThe next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications) but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you. Question Title * 19. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Never Once or Twice Monthly Weekly Daily or Almost Daily Question Title * 20. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Never One or Twice Monthly Weekly Daily or Almost Daily Question Title * 21. How many times in the past year have you used prescription drugs for non-medical reasons? Never Once or Twice Monthly Weekly Daily or Almost Daily Question Title * 22. How many times in the past year have you used illegal drugs? Never Once or Twice Monthly Weekly Daily or Almost Daily Mental HealthOver the past 2 weeks, how often have you been bothered by any of the following problems? Question Title * 23. Little interest or pleasure in doing things? Not at all Several days ago More than half the days Nearly every day Question Title * 24. Feeling down, depressed, or hopeless? Not at all Several days More than half the days Nearly every day Question Title * 25. Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days? Not at all A little bit Somewhat Quite a bit Very much Disabilities Question Title * 26. Because of physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older) Yes No Question Title * 27. Because of physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years or older) Yes No Done
