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Women's Preconception & Inter-conception Health Assessment

Helping women address their social, physical, and mental needs before they get pregnant (preconception) or in between pregnancies (inter-conception) is the best way to increase your overall health. This survey is to better understand your knowledge, attitudes, and behaviors regarding health services and support you may receive from social service agencies.

ALL ANSWERS ON THIS SURVEY WILL BE KEPT 100% CONFIDENTIAL.
1.If you are interested in entering to win $50 in gift cards for completing this survey, please list your name and contact information. Winner will be notified on August 1st.

* entering to win is not required - only submit contact info for prize drawing purposes *
2.Would you like to be entered to win the $50 gift card drawing (info provided on question 1)?(Required.)
3.Are you a Knox County resident?

*please only complete survey if you are a Knox County resident or live in a neighboring county (Licking, Coshocton, Holmes, Ashland, Richland, Morrow, Delaware)*(Required.)
4.Your ZIP code:(Required.)
5.Your age:(Required.)
6.Which of the following best describes you?(Required.)
7.What is the highest degree or level of school you have completed?(Required.)
8.Household yearly income:(Required.)
9.Employment Status:(Required.)
10.Have you heard of the words' preconception health or inter-conception health?(Required.)
11.Where do you seek healthcare information or advice? (check all that apply)(Required.)
12.What barriers do you face when accessing healthcare services? (check all that apply)(Required.)
13.What barriers do you face when accessing social services to help with housing, food, employment, and everyday needs? (check all that apply)(Required.)
14.Do you currently have health insurance coverage (example: Private Insurance, Medicaid, Medicare)?(Required.)
15.Do you have insurance coverage for dental or vision health?(Required.)
16.Are you currently receiving treatment for any chronic health conditions? (check all that apply)(Required.)
17.During the past 30 days, on how many days did you smoke cigarettes or use other tobacco products?

Other tobacco products include cigars, little cigars, cigarillos, e-cigarettes, vapes, vape pens, e-cigars, hookahs, e-hookahs, hookah pens, mods, chewing tobacco, snuff, dip, snus, or dissolvable tobacco products.(Required.)
18.In the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time)(Required.)
19.In the past 7 days, how many times did you eat fruits and/or vegetables? (Do not count fruit juice)(Required.)
20.Have you seen a doctor or other healthcare provider in the past 12 months for a woman wellness exam? (Not including a visit to the Emergency Department or Urgent Care)

A women's wellness visit is a yearly exam that includes having a physical or reproductive exam where a doctor or other healthcare provider offers counseling on how to maintain a healthy lifestyle and conducts screenings for health issues.(Required.)
21.Have you seen a dentist in the past 12 months?(Required.)
22.Have you had an eye exam in the past 12 months?(Required.)
23.Have you seen a mental health provider in the past 12 months? (example: Individual, family, marriage, substance abuse, case management services, etc.)(Required.)
24.What other health services in Knox County do you currently receive/or have received in the past?
25.Do you receive women's health services outside of Knox County? (example: gynecologist, labor & delivery, etc.)(Required.)
26.If you receive women's health services outside of Knox County, what services are they?
27.If you receive women's health services outside of Knox County, why do you prefer receiving services outside of Knox County?
28.Have you experienced any of the following in the past 12 months? (check all that apply)(Required.)
29.What does it mean to you to be "healthy" before you get pregnant?(Required.)
30.What type of birth control method are you currently using and/or have used in the past 12 months? (check all that apply)(Required.)
31.Have you taken a prenatal with folic acid in the past 12 months?(Required.)
32.In the past 12 months have you done any of the following because you were unable to afford to do so? (check all that apply)(Required.)
33.In the past 12 months, have you struggled to pay your rent or mortgage?(Required.)
34.In the past 12 months, have you struggled to buy food or not had enough to eat?(Required.)
35.Do you, or someone in your household, work more than one job to pay your bills?(Required.)
36.Do you have access to affordable childcare?(Required.)
37.Please share any other insight you have on ways to improve the quality and delivery of healthcare offered to Knox County women ages 18-44.
38.What community/lifestyle do you consider yourself a part of? (example: LBGTQIA+, Amish, Appalachian, Migrant Worker, etc.)

* response not required *
THANK YOU for completing the Preconception and Inter-conception Health survey! Your input will guide local women's health professionals in determining how to improve the quality and delivery of healthcare offered to Knox County women ages 18-44.
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