Skip to content
Copy of Community Health Needs Assessment Survey 2022
1.
What is your home address's zip code?
2.
Do you have reliable access to the following? Select all that apply.
Telephone/Cellphone
Internet
Public Transportation: Buses, Access Link
Private Transportation: Cars or Motorcycles
New Age Transportation: Uber/Lyft
3.
Where do you get most of your heath information from? (Check all that apply).
Television
Radio
Newspaper
Magazines
Internet (Websites)
Family/friends/coworkers
Primary care physician/doctor
Social Media (i.e. Facebook)
I do not receive/access any health information.
Other (please specify)
4.
Where do you usually go to receive
routine
medical treatment? If more than one option, specify.
Physicians Office
Emergency Room
Urgent Care
Clinic in a Grocery Store or Drug Store
Telehealth
I do not receive routine healthcare
Other (please specify)
5.
Where does your household go for medical help in an emergency? If more than one option, specify.
Physicians Office
Emergency Room
Urgent Care Clinic
Clinic in a Grocery Store or Drug Store
I do not receive emergency medical help
Other (please specify)
6.
What is your household's primary healthcare coverage? Select all that apply.
Medicare/Managed Medicare
Medicaid/Managed Medicaid
Commercial Health Coverage (Ex. Horizon, AmeriHealth, Aetna)
Exchange Program
No Healthcare Coverage
Other (please specify)
7.
Please rate your ability to obtain healthcare services?
No difficulty
Moderate difficulty
Severe difficulty
No difficulty
Moderate difficulty
Severe difficulty
8.
What is your current level of comfort with receiving medical services?
Unbearable
Uncomfortable
Neutral
Pleasant
Very Enjoyable
Unbearable
Uncomfortable
Neutral
Pleasant
Very Enjoyable
9.
How often have you experienced the following over the past year?
Not at all
Several days
More than half the days
Nearly everyday
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly everyday
Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly everyday
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly everyday
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly everyday
Trouble concentrating on things such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly everyday
10.
Did the COVID-19 pandemic have a significant impact on any of these behaviors?
Yes
No
11.
Has COVID-19 changed your level of health awareness?
Yes
No
12.
How has the COVID-19 pandemic made accessing healthcare services?
Hasn't changed for me
Made it easier
More difficult
Hasn't changed for me
Made it easier
More difficult
13.
Have you received any of the COVID-19 vaccines listed below?
Pfizer-BioNTech
Moderna
Johnson & Johnson/Janssen
None
14.
Do you have access to the COVID vaccine?
Yes
No
15.
Does anyone in your household suffer from any of the following? Select all that apply.
Alcohol addiction
Illegal substance use
Prescription drug misuse
Obesity
Tobacco dependence
None of the above
16.
Choose the following medical services that you are up to date on. Check all that apply.
Annual Wellness Exam
Routine Blood Work (CVC)
Pap smear and HPV testing
Mammography
Flu Shots
Screening for STIs
Prostate Cancer Screening
Smoking cessation
Diet and nutrition services
Annual Women's gyn screenings ( clinical pelvic
Dental Care
Vision Care
None of the above
Other (please specify)
17.
Select the following barriers that restrict you from receiving healthcare in your community? (Check all that apply.)
Cost of care/insurance does not cover cost
Cost of prescriptions and medicine is too high
Fear/distrust of the healthcare system
Healthcare services are not accessible
Health insurance is too expensive
Lack of primary doctors or other primary care providers
Lack of specialty doctors
Medical office hours are inconvenient
Doctor/staff does not speak other languages
Too much paperwork
Lack of access to technology
Knowledge of how to use technology
18.
Select the following barriers that restrict you from making healthy lifestyle choices? (Check all that apply.)
Cost of health clubs or gyms
Cost of healthy food
Lack of knowledge of services available
Lack of motivation and willingness to change
Lack of time/too busy
Lack of transportation
Limited access to healthy food such as fruits and vegetables
Limited access to recreational facilities
Safety or security concerns
19.
What is your gender?
Male
Female
Other (please specify)
20.
What do you identify as? Select all that apply.
Caucasian
African American
Hispanic or Latino
Asian (Chinese, Korean, Japanese, Vietnamese, etc.)
Middle Eastern (Indian, Arab, Egyptian, etc.)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other (please specify)
21.
How old are you?
18-24
25-34
35-44
45-54
55-64
65+
22.
What is your current employment status? Select all that apply.
Employed Full Time
Employed Part Time
Retired
Unemployed
Stay-at-home parent/guardian
Student
Disabled
23.
How many family members reside in your household? (including yourself)
1
10
Clear
24.
What is your annual household income?
Below 20,000
20,001 - 40,000
40,001 - 60,000
60,001 - 100,000
100,000+
25.
If you identify as a member of LGBTQ community, do you believe that you receive adequate medical services?
Yes
No
Doesn't apply