Intro

Population Health  - These questions will focus on the overall health of your community and what does and does not contribute to making it a healthy community for those living in it. This section includes both questions about healthcare and questions on topics like the environment, housing, poverty, etc.


What county do you live in?

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* 1. What county do you live in?

How would you rate the overall health of your community?

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

Why did you select this rating?

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* 3. Why did you select this rating?

What does your community do well to help residents be healthy? (physical, mental, emotional, spiritual) Check Yes or No for each item.


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* 4. What does your community do well to help residents be healthy? (physical, mental, emotional, spiritual) Check Yes or No for each item.


  Yes No
Safe outdoor space
Availability of medical care ie. doctor, dentist, mental health, prenatal care
Courses and Classes (diabetes prevention class, cooking matters, Tai Chi Class)
Play grounds
Walking trails
Farmer’s Market
Rotary
What is your opinion about the following health issues in your community?

Use the following definitions to rank each issue:
Minor Issue: A concern, but much less important that other issues
Moderate Issue: A concern of average importance when compared to other issues
Major Issue: In the top 3 to 5 concerns needing immediate attention

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* 5. What is your opinion about the following health issues in your community?

Use the following definitions to rank each issue:
Minor Issue: A concern, but much less important that other issues
Moderate Issue: A concern of average importance when compared to other issues
Major Issue: In the top 3 to 5 concerns needing immediate attention

  Not an Issue Minor Issue Moderate Issue Major Issue Don’t Know
Water Quality
Air Quality
Oral Health
Teen Birth Rates/Teen Pregnancy
Obesity/Overweight (diabetes, heart disease)
Tobacco Smoking/Vaping
Substance use/misuse (alcohol, prescription drug use, illicit drugs ie. heroin, meth, fentanyl)
Recreational marijuana use
Mental Health (stress)
Injuries (suicide, self-harm, work-related accidents, car accidents, sexual violence)
Safety (domestic violence, community crimes)
How concerned are you about these other community issues that impact health?
Use the following definitions to rank each issue:
Minor Issue: A concern, but much less important that other issues
Moderate Issue: A concern of average importance when compared to other issues
Major Issue: In the top 3 to 5 concerns needing immediate attention

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* 6. How concerned are you about these other community issues that impact health?
Use the following definitions to rank each issue:
Minor Issue: A concern, but much less important that other issues
Moderate Issue: A concern of average importance when compared to other issues
Major Issue: In the top 3 to 5 concerns needing immediate attention

  Not an Issue Minor Issue Moderate Issue Major Issue Don’t Know
Presence of Radon in homes
Lack of Education
Availability of Exercise or fitness opportunities
Availability of jobs
Support for families with children (day care, safe places to play)
Income (hard to pay bills)
Access to Healthy Foods (available stores, affordability)
Transportation
Travel distance for health care needs
Quality of Housing
Availability of Housing
Housing is affordable
Bullying (school youth, cyber, social pressure)
Support for special needs populations and their caretakers(ie physically disabled, mentally disabled, and elderly)
Hospital Specific - These questions will focus on specific healthcare services available to you in your community, and the type of  health services you can access at the hospital.
Do you have a primary care provider?

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* 7. Do you have a primary care provider?

Have you or someone in your household delayed healthcare due to lack of money and/or insurance?

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* 8. Have you or someone in your household delayed healthcare due to lack of money and/or insurance?

Where do you receive your healthcare? Check all that apply.

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* 9. Where do you receive your healthcare? Check all that apply.

Within the last 2 years, what services have you needed and received at another place other than Mt. San Rafael Hospital? Check yes or no for each item.

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* 10. Within the last 2 years, what services have you needed and received at another place other than Mt. San Rafael Hospital? Check yes or no for each item.

  Yes No
Radiological imaging (X-ray, MRI, CT, Ultrasound, Mammogram, Dexa Scan)
Laboratory
Physical, Occupational or Speech Therapy
Emergency room (ER)
Colonoscopy/Endoscopy
General Surgery
Gynecology
What specialists have you or someone in your household used in the past 2 years? Check yes or no for each item.

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* 11. What specialists have you or someone in your household used in the past 2 years? Check yes or no for each item.

  Yes No
Allergy
Dialysis
Cardiology/Heart
Asthma
Obstetrics-Gynecology
Obesity
Orthopedic Surgery
Diabetes
Neurosurgery
Podiatry
Vascular Surgery
ENT
Dermatology
Oncology
Pain Management
Urology
Audiology
Do you believe your local hospital, health department or clinic has services that support residents in managing their own health – in other words, helping residents to be more aware of available healthcare resources, home health services, and of disease prevention?

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* 12. Do you believe your local hospital, health department or clinic has services that support residents in managing their own health – in other words, helping residents to be more aware of available healthcare resources, home health services, and of disease prevention?

If no, why not?

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* 13. If no, why not?

What is the best way to raise awareness about health services in your community? Check all that apply

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* 14. What is the best way to raise awareness about health services in your community? Check all that apply

What is your age?

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* 15. What is your age?

What is the gender you identify with today?

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* 16. What is the gender you identify with today?

Which one or more of the following would you say is your race? (Choose all that apply.)

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* 17. Which one or more of the following would you say is your race? (Choose all that apply.)

What is the highest degree or level of school you have completed? (If currently enrolled, choose highest degree received.)

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* 18. What is the highest degree or level of school you have completed? (If currently enrolled, choose highest degree received.)

What is your current employment status?

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* 19. What is your current employment status?

What type of health insurance do you have currently? (Check all that apply)

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* 20. What type of health insurance do you have currently? (Check all that apply)

What is your annual household income range?

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* 21. What is your annual household income range?

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