100% of survey complete.

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* 1. What is your zip code?
(As the goal of this survey is to indicate the health care needs of individuals living in our primary and secondary market areas we ask that only those residing in the zip codes list below respond to this survey.)

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* 2. What is your age?
(Please discountinue this survey if you are under the age of 18.)

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* 3. How many individuals live in your household?

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* 4. Number of

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* 5. Do you have a primary healthcare provider?

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* 6. If you have a primary healthcare provider, what is his/her name?

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* 7. Are you able to get an appointment with your primary healthcare provider when you need one?

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* 8. If you don't have a primary healthcare provider what do you do when you need medical care?

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* 9. Do you think there are enough primary healthcare providers in your area?

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* 10. Do you have a chronic medical condition?

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* 11. If you have a chronic medical condition, are you receiving routine medical care for the condition?

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* 12. Has anyone in your household seen a specialist within the past 12 months?

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* 13. If you or someone in your household haS seen a specialist within the last year, what type of specialist and in what town/city?
(Example: Neurologist, Erie, PA)

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* 14. If a specialist was seen, did the specialist(s) require additional testing such as lab work, imaging services, cardiac tests, pulmonary tests, etc?

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* 15. If the specialist(s) ordered additional testing, was the testing performed at Charles Cole Memorial Hospital?

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* 16. If the specialist(s) ordered tests and they were not performed at Charles Cole Memorial Hospital, where were they performed? (Example: MRI, Geisinger Hospital)

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* 17. If you had tests performed at a location other than Charles Cole Memorial Hospital, why did you have the tests performed somewhere else?

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* 18. In the past year were you unable to afford a prescription medication?

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* 19. Do you and/or members of your household have any type of medical insurance?

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* 20. If you and/or someone in your household does have medical insurance, how are they insured?

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* 21. Are you or someone in your household looking for a certain type of medical service that is not provided in your area? (Example: Endocrinology)

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* 22. Have you or someone in your household received services from Charles Cole Memorial Hospital, with the exception of emergency department visits and routine office visits, within the last year?

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* 23. If you or someone in your household has received services from Charles Cole Memorial Hospital within the last year, what services were received (excluding emergency department and routine office visits)?

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* 24. If you received services from Charles Cole Memorial Hospital within the last year, were you satisfied or dissatisfied?

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* 25. Have you or someone in your household received services, with the exception of emergency department visits and routine office visits, within the last year some place other than Charles Cole Memorial Hospital?

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* 26. If you or someone in your household has received services within the last year from some place other than Charles Cole Memorial Hospital, where did you receive services (excluding emergency department and routine office visits)? (Example: Hamot, Erie, PA)

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* 27. Have you or someone in your household used emergency department services within the last year?

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* 28. If you received services some place other than Charles Cole Memorial Hospital, why did you choose to go some place else?

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* 29. If you or someone in your household did receive emergency department services, what town/city did you receive care?

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* 30. If you or someone in your household did receive emergency department care, why did you need emergency care? (Example: abdominal pain)

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* 31. Were you satisfied or dissatisfied with the emergency department care that you received?

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* 32. Have you or someone in your household had a healthcare concern/issue for which you did not seek medical care within the last year?

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* 33. If you or someone in your household had a concern/issue for which you didn't seek medical care, why didn't you seek care?

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* 34. Has everyone in your household had a dental check-up within the last year?

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* 35. If no, why didn't everyone in your household have a dental check-up within the last year?

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* 36. Do you have trouble accessing healthcare due to transportation issues?

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* 37. Do you read the nutrition labels on the food you are buying?

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* 38. How would you rate your overall health?

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