Klamath County Community Health Assessment Survey

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* 2. In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor

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* 3. Do you have reliable transportation?

Yes

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* 4. Do you find public transportation convenient and easy to use?

Yes

I do not use it

No (Please explain why)

Why did you select no?

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* 5. In the past 12 months, have you worried that your food would run out before you got money to buy more?

Never

Seldom

Sometimes

Often

Always

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* 6. What is your housing situation today?

I do not have housing

I am staying with others

I have housing

I have housing today, but I am worried about losing housing in the future

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* 7. In the past 12 months, have you used any of the following services? Check all that apply.

Medical check up

Teeth cleaning/dental exam

Emergency room (ER)

Mental health

Appointment for a recent illness (such as a cold or flu, or an injury)

Appointment for an on-going illness (such as heart disease, diabetes, cancer)

Pharmacy

None of the above

Other (please specify)

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* 8. In the past 12 months have any of the following issues kept you from using health care services? Check all that apply.

Cost

Transportation

Insurance

Childcare

Work

Distance/weather concerns

Illness/disability

Substance use

Could not get an appointment

None of these

Other (please specify)

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* 9. If there was an issue that kept you from using health care services, which of the following were you unable to use? Check all that apply.

Medical check up

Teeth cleaning/dental exam

Emergency room (ER)

Mental health

Appointment for a recent illness (such as a cold or flu, or an injury)

Appointment for an on-going illness (such as heart disease, diabetes, cancer)

Pharmacy

None of the above

Not applicable

Other (please specify)

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* 10. In the past 30 days have you had a medical, dental, or mental health appointment you missed or skipped?

Yes

I did not have an appointment

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* 11. In the past 30 days, how often did mental health concerns (such as depression, anxiety or other mental health issues) make it hard for you to do your usual activities, such as self-care or work?

Never

Seldom

Sometimes

Often

Always

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* 12. In the past 30 days, how often did pain make it hard for you to do your usual activities, such as self-care or work?

Never

Seldom

Sometimes

Often

Always

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* 13. If you are a member of Cascade Health Alliance, have you been offered case management?

Not applicable

Yes

I don’t know

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* 14. Is there anything you feel is keeping you from having better health? Check all that apply.

Chronic illness

Mental health issue

Alcohol use

Addiction or drug use

Access to healthcare

Tobacco use

Lack of healthy foods

Lack of physical activity

Cost

Geographic isolation

Social isolation

Abuse or violence

None of the above

Other (please specify)

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* 15. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75 or older

Prefer not to answer

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* 16. What is the highest level of education you completed?

Some high school, elementary school, or less

High school diploma/GED

Some college

Trade school/certificate

Associate’s degree

Bachelor’s degree or higher

Prefer not to answer

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* 17. How many people usually live in your household?

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* 18. What is your yearly household income?

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* 19. Do you have health insurance?

Yes

Prefer not to answer

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* 20. If you have insurance, what type do you have?

Private insurance

Employer sponsored

Medicaid (Oregon Health Plan, Open Card)

Medicare

TRICARE

Veterans Affairs (VA)

Indian Health Services (HIS)

Other

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* 21. What is your employment status?

Full-time

Part-time

Self-employed

Unable to work due to medical condition, disability, etc.

Out of work and looking for work

Out of work but not currently looking for work

Other (homemaker, student, retired)

Prefer not to answer

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* 22. What is your gender identity?

Male

Female

Transgender

Prefer not to answer

Other (please specify)

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* 23. How would you describe your sexual orientation?

Heterosexual (straight)

Gay/Lesbian

Bisexual

Prefer not to answer

Other (please specify)

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* 24. What is your race?

White

Black or African American

Native American or Alaska Native

Multiracial

Other

Prefer not to answer

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* 25. Do you identify as Hispanic or Latina/Latino?

Yes

Prefer not to answer

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* 26. Select all of the languages spoken in your home:

English

Spanish

Klamath/Modoc

Other

Prefer not to answer

Klamath County Community Health Assessment Survey

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* 1. Where in Klamath County do you live?

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* 2. In general, would you say your health is:

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* 3. Do you have reliable transportation?

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* 4. Do you find public transportation convenient and easy to use?

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* 5. In the past 12 months, have you worried that your food would run out before you got money to buy more?

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* 6. What is your housing situation today?

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* 7. In the past 12 months, have you used any of the following services? Check all that apply.

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* 8. In the past 12 months have any of the following issues kept you from using health care services? Check all that apply.

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* 9. If there was an issue that kept you from using health care services, which of the following were you unable to use? Check all that apply.

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* 10. In the past 30 days have you had a medical, dental, or mental health appointment you missed or skipped?

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* 11. In the past 30 days, how often did mental health concerns (such as depression, anxiety or other mental health issues) make it hard for you to do your usual activities, such as self-care or work?

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* 12. In the past 30 days, how often did pain make it hard for you to do your usual activities, such as self-care or work?

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* 13. If you are a member of Cascade Health Alliance, have you been offered case management?

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* 14. Is there anything you feel is keeping you from having better health? Check all that apply.

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* 15. What is your age?

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* 16. What is the highest level of education you completed?

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* 17. How many people usually live in your household?

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* 18. What is your yearly household income?

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* 19. Do you have health insurance?

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* 20. If you have insurance, what type do you have?

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* 21. What is your employment status?

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* 22. What is your gender identity?

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* 23. How would you describe your sexual orientation?

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* 24. What is your race?

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* 25. Do you identify as Hispanic or Latina/Latino?

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* 26. Select all of the languages spoken in your home: