CIHSC - Population Engagement Survey

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* 1. How old are you

17 or under

18-30

31-65

65 or older

I'd rather not say

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* 2. What is your sex?

Male

Female

Other

I'd rather not say

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* 3. What is your current living situation?

I live alone

I live with my family or a family member

I live with a friend or spouse

I live in a group home

I live in a home share

I'd rather not say

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* 4. How would you rate your current physical health?

Excellent

Very good

Good

Fair

Poor

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* 5. How would you rate your current mental health?

Excellent

Very good

Good

Fair

Poor

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* 6. Do you know people in your neighbourhood, work, school, programs or church?

Yes, I know a lot of people in my community and have a lot of close friends

I know some people in my community but I find it hard to make close friends

I have some close friends but I don’t know many other people in my community

I don’t know many people in my community and I find it hard to make close friends

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* 7. Do you feel safe and included in your community?

Yes, very safe and included

Somewhat safe and included

Neutral

Not safe and included at all

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* 8. When you are prescribed medication by a doctor, do you need help to make sure you follow the directions properly?

No, I manage my own medications

Yes, I rely on a family member or friend

Yes, I rely on a service provider

Yes, I rely on a caregiver

I'm not sure

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* 9. When you need to visit a doctor or access a community program, who makes the appointment?

I make all of my own appointments

I make most of my own appointments, but sometimes I need help

A family member or friend makes most or all of my appointments for me

A service provider makes most or all of my appointments for me

A caregiver makes most or all of my appointments for me

I don't know

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* 10. Do you have a family doctor in your community?

Yes, I have a family doctor that I visit in my community

No, I have a family doctor but I need to travel outside of my community to visit them

No, I do not have a family doctor

I'm not sure

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* 11. Do you see a dentist in your community?

Yes, the services available exceed my needs

Yes, all of my needs are met

Yes, but only my basic needs are met

No, services do not meet my needs

I don't know

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* 12. Do you have access to sufficient sexual health services in your community?

Yes, the services available exceed my needs

Yes, all of my needs are met

Yes, but only my basic needs are met

No, services do not meet my basic needs

I don't know

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* 13. Do you have sufficient mental health services in your community?

Yes, the services available exceed my needs

Yes, all of my needs are met

Yes, but only my basic needs are met

No, services do not meet my basic needs

I don't know

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* 14. How often do you have to travel outside of your community to receive medical treatment?

Never

Rarely

Sometimes

Often

Always

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* 15. How confident are you in your ability to determine what food is healthy?

Very confident

Somewhat confident

Not very confident

Not confident at all

I'm not sure

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* 16. How confident are you in your ability to set healthy exercise goals?

Very confident

Somewhat confident

Not very confident

Not confident at all

I'm not sure

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* 17. Does your health ever prevent you from participating in your community?

Never

Rarely

Sometimes

Often

Always

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* 18. Do you ever not follow the doctor's directions or access a health service because it would be too expensive?

Never

Rarely

Sometimes

Often

Always

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* 19. When you share your opinions and feelings with a doctor or health professional, do you feel like they listen?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never

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* 20. When you share your opinions with staff or volunteers at community programs, do you feel like they listen?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never

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* 21. Do you feel that doctors and health professionals take enough time to make sure you understand their directions?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never

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* 22. Do you feel that staff or volunteers at community programs take enough time to make sure you understand their directions?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never

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* 23. When you use health services, are there materials available that use inclusive language?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never

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* 24. When you use community programs, are their materials available that use inclusive language?

Yes, all of the time

Yes, most of the time

Yes, but only sometimes

No, not very often

No, never