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Community Health Needs Assessment Survey
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1.
Gender:
(Required.)
Female
Male
*
2.
Age Category:
(Required.)
20-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
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3.
Marital Status:
(Required.)
Single
Married
Divorced
Widowed
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4.
How many people live in your household including yourself?
(Required.)
*
5.
Race/Ethnic Origin:
(Required.)
Caucasian
Hispanic
Asian
African
Native American
Other (please specify)
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6.
Highest level of school you have completed:
(Required.)
Jr. High
High School
2 years College
3 years College
Bachelor Degree
Associates Degree
Masters
Doctorate
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7.
What is your zip code?
(Required.)
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8.
Are you the primary care giver for any of the following?
(Required.)
A child under the age of 18
A disabled child under the age of 18
An older adult
No one - self only
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9.
Do you:
(Required.)
Own your home
Rent
Live in another's home/apartment
Live in an assisted living facility
Live in a nursing home
Live in subsidized housing
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10.
Do you have any of the following in your home?
(Required.)
Internet
Cell phone
Land line phone
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11.
Do you feel safe in your neighborhood?
(Required.)
Yes
No
12.
What do you think is healthy about our community?
13.
What do you think is unhealthy about our community?
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14.
In the past 12 months, have you or someone you know had difficulty getting needed healthcare?
(Required.)
Yes
No
If Yes, what service?
15.
If you do NOT have health insurance is it because (fill in all that apply):
Dropped by an insurance company
Lost employment
Cannot afford it
Denied due to pre-existing condition
No longer qualify for Medicaid
16.
What do you think is the most pressing health care related need for you, your family or our community?
*
17.
In the past 12 months, have you had a(n) (fill in all that apply):
(Required.)
Yes
No
I'm Not Sure
General Health exam
Yes
No
I'm Not Sure
Blood pressure check
Yes
No
I'm Not Sure
Cholesterol check
Yes
No
I'm Not Sure
Flu shot
Yes
No
I'm Not Sure
Pneumonia shot
Yes
No
I'm Not Sure
Skin cancer screen
Yes
No
I'm Not Sure
Blood Stool test
Yes
No
I'm Not Sure
Dental exam/teeth cleaned
Yes
No
I'm Not Sure
Breast exam
Yes
No
I'm Not Sure
Mammogram
Yes
No
I'm Not Sure
Diabetes check
Yes
No
I'm Not Sure
Eye exam
Yes
No
I'm Not Sure
Hearing exam
Yes
No
I'm Not Sure
Colon exam
Yes
No
I'm Not Sure
Ultrasound
Yes
No
I'm Not Sure
Stress Test
Yes
No
I'm Not Sure
Biopsy
Yes
No
I'm Not Sure
Surgery
Yes
No
I'm Not Sure
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18.
Have you been hospitalized in the last:
(Required.)
6 months
12 months
2 - 5 years
5 - 10 years
Longer than 10 years
Never
19.
In what ways do you think the hospital is serving the community well?
20.
In what ways could the hospital improve the way in which it serves the community?
21.
What services do you feel are needed in our community that currently do not exist?
22.
Do you see community members working together in collaboration to address community health needs?
Yes
No
Please explain:
23.
What is the number one thing the hospital could do to improve the health and quality of life of the community?
24.
Any other comments you think are important to address in this survey?