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Community Health Needs Assessment Survey
1.
What are the biggest health issues or concerns in our community? (check all that apply)
Mental Health / Depression
Chronic Pain
Dental Problems
Diabetes
Cancer
Maternity Care
Asthma / Lung Disease
Heart Disease
Hypertension
Stroke
HIV/AIDS
Other (please specify)
2.
What barriers do people face when they want to access medical, mental health, dental, or other healthcare services? (check all that apply)
Lack of insurance
Health Services too far away
Not ready to face health problem
Frequent turnover of doctors
Limited access to specialty care services
Limited access to mental health care services
Financial barriers
Limited access to primary care doctors
Fear
Navigation of the healthcare system
Transportation
Long wait times to get an appointment
Co-pay and deductible costs
Prescription costs
Doctors not taking new patients
Appointment availability
No same day appointments available
Balancing work, home, kids’ schedules, and time constraints
Finding a provider covered by insurance plan
Knowledge of available services
Do not understand the need to see a doctor
Appointment schedule options versus work schedule
Language barriers / do not speak my language
Childcare
Cultural or religious beliefs
None/No barriers
Other (please specify)
3.
What is needed to improve the health of your family and neighbors? (Check all that apply)
Preventative Care
Housing
Timely, available, affordable primary care access
Infant & Maternal Health
Mental heath services
Senior services
Dental care
Job opportunities
Wellness services
Specialty physicians
Substance abuse rehabilitation services
Youth services
Healthy food
Less stress
Help navigating the health care system
Low-cost transportation
Recreation facilities
Health advocates
Access to gym
Nutrition counseling, meal planning
Physical fitness
Parks and green spaces
Safe places to walk
Longer clinic hours to access care before or after work
Smoking cessation
Work-life balance
Grief support
Healthy choices at restaurants
Safe neighborhood
Other (please specify)
4.
Where do you and your family get most of your health information? (check all that apply)
Doctor or health professional
Internet
Family or friends
Hospital
Newspaper or magazines
Community announcements
Television
Health Department
Library
Radio
School
Health fairs
Social Workers
Religious Organizations
Other (please specify)
5.
What healthy changes have you made in the past year to improve your health? (check all that apply)
Eating more fruits and vegetables
Drinking more water
Eating less sugar, salt, and processed foods
Annual check-up
No soda
Taking Vitamins
Dental Exam
Eating more organic foods
Flu or pneumonia vaccine
Walking more
More sleep
Eating less meat
Reduced stress
Smaller portions
Checking food labels for calories
Mental health counseling
Weight loss
Reducing carbohydrates
Started exercising
Stopped smoking
Other (please specify)
6.
What health goals are you planning on working on in 2021? (check all that apply)
Stay fit and active
Eat healthier
Decreased stress
Lose weight, weight control
Healthy lifestyle
More “me” time, self-care
Improve sleep
Meditate daily
Control blood pressure
Pain control
Start a new exercise program
Manage chronic diseases
Less screen time
Break a habit
Stop smoking
Other (please specify)
7.
If you or someone in your family were ill and required medical care, where would you go?
Clinic
Doctor’s office
Hospital Emergency Department
Urgent Care Center
Would not seek care
Other (please specify)
8.
Have you had a physical exam in the past two years?
Yes
No
9.
Are your immunizations up to date?
Yes
No
10.
Will you get a COVID-19 vaccination when it is available?
Yes
No
11.
Which of the following describes the primary household members employment situation?
Government benefits or pension (Social Security, Pension, Unemployment benefits)
Hourly employee
Retired
Self-employed
Had multiple jobs or multiple sources of income
Salaried employee
No income / unemployed
Other (please specify)
12.
What is the primary language spoken at home?
English
Spanish
Chinese
Tagalog
Vietnamese
Russian
French
Japanese
Korean
Arabic
Other (please specify)
13.
What is the total household income before taxes last year?
Less than $20,000
$20,000 - $50,000
$50,000 - $80,000
$80,000 - $100,000
Over $100,000
14.
Does the household participate in any of the following programs? (check all that apply)
SNAP/Food Stamps
WIC
TANIF
None
15.
Do you rent or own your home?
Rent
Own
Other (please specify)
16.
What is your zip code?
17.
What is your gender? (check all that apply)
Male
Female
Transgender
Gender neutral
Non-binary
Agender
Pangender
Genderqueer
Two-spirit
Third gender
Prefer not to say
Other (please specify)
18.
What category below includes your age?
Under 18
18-29
30-39
40-49
50-59
60-69
70-79
80-89
90 or older
Prefer not to say
19.
What is your racial/ethnic identification?
White/Caucasian
Black/African American
Latinx / Chicano
Asian
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Other (please specify)
20.
What is your highest level of education?
Some high school
High school equivalent - GED
High school diploma
Some college
Associate’s degree
Bachelor’s degree
Master’s degree
Doctorate
Other (please specify)
21.
Do you have health insurance?
Medicare
Medi-Cal
San Francisco Health Plan (SFHP)/Healthy SF
Affordable Care Act/Covered California
Veterans Health
Employer-sponsored private insurance
Non-Employer sponsored health insurance
No insurance
Other (please specify)
22.
For the following sections select all that applied to you in 2020:
Wages and Employment
Earned less money
My workload increased
Worked fewer hours
Worked more hours
Lost job
Had to take off work without pay
Had to close business
23.
Medical and Health
Received medical services (non-emergency)
Nervous to go into a health center or hospital
Received dental services
Had one or more telehealth visits
Had a COVID-19 test
Received mental health services
Had a medical emergency
Had an increase in medical expenses
Could not get daily medication refilled
Other (please specify)
24.
Family and Wellbeing
Felt like you could not leave your home
Not much change
Felt isolated
Could not relax
Worried about child’s socialization
Felt hopeless
More conflict in the household
Had to provide care to an elder
Did not have household goods (soap, paper towels, toilet paper, cleaning supplies)
Someone moved into the household
Needed help with childcare
Someone moved out of the household
There was not enough food
Felt one or more of these because of COVID-19
Other (please specify)
25.
Education and Schooling
Had a child at home because a school/childcare/college closed
Worried students would not be ready for the next school year
Did not have Wi-Fi or internet at home
Lacked information from school district
Did not have a computer, tablet, or other device for doing schoolwork
Other (please specify)
26.
Do you have any other comments about the health of our community?
27.
If you are interested in participating in a focus group centered around discussing the needs of the Bayview community, please leave your name and contact information below.
28.
Comments
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