Two Stone Harbor Blvd.
Cape May Court House, NJ 08210
Phone: (609)-463- 4042  Fax: (609- 463-4039)

Cape Regional Medical Center is working with other healthcare partners throughout the community to identify the health care needs of the people who live in Cape May County. Thank you for helping us. All information will be kept confidential.

Survey may take approximately 15 minutes to complete.
I. General Information:

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* 1. What is your age? (Select One)

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* 2. How do you identify: (Select One)

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* 3. What is your race/ ethnicity? (Select all that apply)

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* 4. What is your marital status?(Select one)

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* 5. What is the Zipcode for the town you live in?

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* 6. What is the number of people living in your household?

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* 7. What type of housing do you currently live in? (Select one)

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* 8. Do you have health insurance? (Select one)

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* 9. What is your employment status? (Select all that apply)

II. Adult Health: 
Has a healthcare provider told you that you have any of the following conditions? (Select yes or leave blank if no ) If so, are you receiving professional health care? (Select yes or no)

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* 10. Auto Immune

  Have Condition Receiving Medical Care
Celiac Disease
Fibromyalgia
Other

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* 11. Blood Disorders

  Have Condition Receiving Medical Care
Hemophilia
Clots
Other

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* 12. Bone/Joint Issues

  Have Condition Receiving Medical Care
Arthritis
Falling
Osteoporosis
Other

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* 13. Brain Injury

  Have Condition Receiving Medical Care
Stroke
TIA
Concussion
Accident
PTSD
Other

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* 14. Cancer

  Have Condition Receiving Medical Care
Breast
Colon
Melanoma
Lung
Prostate
Skin
Other

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* 15. Memory Issues

  Have Condition Receiving Medical Care
Alzheimer's
Behavioral Issues
Memory Loss
Other

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* 16. Dental Issues

  Have Condition Receiving Medical Care
Dental Issues

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* 17. Diabetes

  Have Condition Receiving Medical Care
Diabetes

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* 18. Disabilities

  Have Condition Receiving Medical Care
Developmental/Physical
Mental/Intellectual
Other

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* 19. Gastrointestinal

  Have Condition Receiving Medical Care
Crohn's disease
Hepatitis
Other

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* 20. Hearing Issues

  Have Condition Receiving Medical Care
Hearing Issues

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* 21. Heart Issues

  Have Condition Receiving Medical Care
Atrial Fibrillation (A-Fib)
Congestive Heart Failure (CHF)
Heart Attack
High Cholesterol (Hyper Lipids)
Other

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* 22. High Blood Pressure

  Have Condition Receiving Medical Care
High Blood Pressure

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* 23. Lung Disease

  Have Condition Receiving Medical Care
Asthma
COPD
Other

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* 24. Mental Health Issues

  Have Condition Receiving Medical Care
Anxiety
Bipolar
Depression
Other

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* 25. Neurological Issues

  Have Condition Receiving Medical Care
Multiple Sclerosis
Neuropathy
Parkinson's Disease
Seizures

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* 26. Pain

  Have Condition Receiving Medical Care
Pain

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* 27. Social Issues

  Have Condition Receiving Medical Care
Alcohol dependency
Domestic abuse
Sexual abuse
Drug abuse (prescription or recreational)
Tobacco use
Vaping
e-cig

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* 28. STD (Sexually Transmitted Disease)

  Have Condition Receiving Medical Care
HIV
AIDS
Other

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* 29. Weight Management

  Have Condition Receiving Medical Care
Overweight
Obese
Underweight

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* 30. Vision

  Have Condition Receiving Medical Care
Cataracts
Glaucoma
Macular Degeneration
Retinopathy

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* 31. Other conditions/concerns you may have

III. Barriers to Healthcare

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* 32. What are the barriers to healthcare for you and your family? (Check all that apply)

IV. Children’s Health: If you have children under the age of 18 living in your household, please answer the following questions.

Has a healthcare provider told you that your child/ children have any of the following health issues? (Select yes or leave blank if no) If so, are they receiving professional health care? (Select yes or no)

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* 33. Allergies

  Have Condition Receiving Medical Care # Children with Each Condition
Food
Seasonal
Medication
Other

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* 34. Autism

  Have Condition Receiving Medical Care # Children with Each Condition
Autism

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* 35. Bone/Joint Issues

  Have Condition Receiving Medical Care # Children with Each Condition
Joint Pain
Rheumatoid Arthritis
Other

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* 36. Brain Injury

  Have Condition Receiving Medical Care # Children with Each Condition
Concussion
Accident
Other

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* 37. Cancer

  Have Condition Receiving Medical Care # Children with Each Condition
Brain
Breast
Bone
Leukemia
Melanoma or skin
Other

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* 38. Dental Issues

  Have Condition Receiving Medical Care # Children with Each Condition
Dental Issues

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* 39. Diabetes

  Have Condition Receiving Medical Care # Children with Each Condition
Diabetes

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* 40. Disabilities

  Have Condition Receiving Medical Care # Children with Each Condition
Developmental
Physical
Learning
Mental Intellectual

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* 41. Elevated Lead Levels

  Have Condition Receiving Medical Care # Children with Each Condition
Elevated Lead Levels

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* 42. Hearing Difficulties

  Have Condition Receiving Medical Care # Children with Each Condition
Hearing Difficulties

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* 43. Heart Issues

  Have Condition Receiving Medical Care # Children with Each Condition
High Cholesterol
High blood pressure
Birth defect
Other

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* 44. Lung Disease

  Have Condition Receiving Medical Care # Children with Each Condition
Asthma
Reactive air way

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* 45. Mental Health Issues

  Have Condition Receiving Medical Care # Children with Each Condition
ADD/ADHD
Anxiety
Behavioral Issues
Bipolar
Bullying
Depression
Mood Disorder

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* 46. Social Issues

  Have Condition Receiving Medical Care # Children with Each Condition
Alcohol dependency
Child neglect
Trauma
Sexual abuse
Drug abuse (prescription and/or recreational)
Tobacco use
e-cig
Vaping

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* 47. Neurological Issues

  Have Condition Receiving Medical Care # Children with Each Condition
Seizures

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* 48. STD (Sexually Transmitted Disease)

  Have Condition Receiving Medical Care # Children with Each Condition
HIV/AIDS
Other

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* 49. Weight Management

  Have Condition Receiving Medical Care # Children with Each Condition
Underweight
Overweight
Obese

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* 50. Eating Disorder

  Have Condition Receiving Medical Care # Children with Each Condition
Anorexia
Binge Eating
Bulimia
Other

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* 51. Vision Problems

  Have Condition Receiving Medical Care # Children with Each Condition
Vision Problems
V. Infection Exposure/Safety Concerns

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* 52. Do you have any safety concerns regarding exposures to infection in the following locations? (Select all that apply)

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* 53. If you tested positive for COVID-19, would you be interested in coming to the hospital to address any post-COVID related concerns?

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* 54. If you tested positive for COVID-19, what post-COVID concerns do you have? (Check all that apply)

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* 55. What concerns you the most, as it relates to COVID, about receiving services at the hospital

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* 56. Would you prefer to use Telehealth services for all non-emergent needs instead of coming to the hospital for fear of COVID?

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* 57. Do you take advantage of health screens offered by the hospital? If so, which ones?

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* 58. Are you willing to come to the hospital for a health screen? If not, are you comfortable receiving a health screen at an off-site location? (Select Yes or No for each)

 
Hospital
Off-Site Location
THANK YOU!!!!!

T