Copy of Community Health Needs Assessment Survey 2022 Question Title * 1. What is your home address's zip code? Question Title * 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 Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 7. Please rate your ability to obtain healthcare services? No difficulty Moderate difficulty Severe difficulty No difficulty Moderate difficulty Severe difficulty Question Title * 8. What is your current level of comfort with receiving medical services? Unbearable Uncomfortable Neutral Pleasant Very Enjoyable Unbearable Uncomfortable Neutral Pleasant Very Enjoyable Question Title * 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 Feeling down, depressed, or hopeless Not at all Feeling down, depressed, or hopeless Several days Feeling down, depressed, or hopeless More than half the days Feeling down, depressed, or hopeless Nearly everyday Trouble falling or staying asleep, or sleeping too much Trouble falling or staying asleep, or sleeping too much Not at all Trouble falling or staying asleep, or sleeping too much Several days Trouble falling or staying asleep, or sleeping too much More than half the days Trouble falling or staying asleep, or sleeping too much Nearly everyday Feeling tired or having little energy Feeling tired or having little energy Not at all Feeling tired or having little energy Several days Feeling tired or having little energy More than half the days Feeling tired or having little energy Nearly everyday Poor appetite or overeating Poor appetite or overeating Not at all Poor appetite or overeating Several days Poor appetite or overeating More than half the days Poor appetite or overeating Nearly everyday Trouble concentrating on things such as reading the newspaper or watching television Trouble concentrating on things such as reading the newspaper or watching television Not at all Trouble concentrating on things such as reading the newspaper or watching television Several days Trouble concentrating on things such as reading the newspaper or watching television More than half the days Trouble concentrating on things such as reading the newspaper or watching television Nearly everyday Question Title * 10. Did the COVID-19 pandemic have a significant impact on any of these behaviors? Yes No Question Title * 11. Has COVID-19 changed your level of health awareness? Yes No Question Title * 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 Question Title * 13. Have you received any of the COVID-19 vaccines listed below? Pfizer-BioNTech Moderna Johnson & Johnson/Janssen None Question Title * 14. Do you have access to the COVID vaccine? Yes No Question Title * 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 Question Title * 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) Question Title * 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 Question Title * 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 Question Title * 19. What is your gender? Male Female Other (please specify) Question Title * 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) Question Title * 21. How old are you? 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 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 Question Title * 23. How many family members reside in your household? (including yourself) 1 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 24. What is your annual household income? Below 20,000 20,001 - 40,000 40,001 - 60,000 60,001 - 100,000 100,000+ Question Title * 25. If you identify as a member of LGBTQ community, do you believe that you receive adequate medical services? Yes No Doesn't apply Done