Hillsdale Community Health Assessment Survey

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* 1. Are you:

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* 2. Are you a Hillsdale County resident?

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* 3. What is your Age?

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* 4. How would you best describe your race?

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* 5. How would you best describe your ethnic background?

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* 6. What best describes your employment situation?

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* 7. What best describes your living situation?

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* 8. What best describes your marital status?

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* 9. How many children under age 18 live in your home?

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* 10. What is the highest grade you completed in school?

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* 11. Are you a caregiver for any sick or aged person?

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* 12. If you are a caregiver, how would you rate the healthcare service or support currently being
received?

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* 13. Do you currently have health insurance?

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* 14. If you have health insurance, is it through:

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* 15. If your insurance is through your employer, is it a Health Savings Account?

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* 16. Do you have a regular doctor (personal physician)?

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* 17. If you have a  regular doctor, is your doctor in Hillsdale County?

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* 18. If you have a regular doctor, how often do you normally visit your doctor each year?

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* 19. If you have health insurance, does your plan cover:

  Yes No
Prescriptions
Dental work
Eye exams/glasses

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* 20. In the past year, have you ever gone without food or utilities to pay for prescription drugs, or gone without a prescription drug to pay for food or utilities?

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* 21. In the past year, have you ever avoided going to a doctor because of cost?

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* 22. If you need medical treatment (not counting accidents or a crisis such as a heart attack), where do you normally go?

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* 23. Do you have:

  Yes No Don't know
Arthritis
Asthma
COPD
Diabetes
Fibromyalgia
Heart Disease
High Blood Pressure
High Cholesterol
High or Low Thyroid
Migraines
Other chronic disease

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* 24. Do you currently smoke?

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* 25. Do you currently drink alcohol?

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* 26. If you currently drink alcohol, is it:

  Yes No
More than one drink a day?
More than three a day?

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* 27. Do you currently use any illegal drugs?

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* 28. Do you use a prescription drug to manage chronic pain?

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* 29. If you use a prescription drug to  manage chronic pain, is it:

  Yes No
Oxycontin
Vicodin
Codeine
Other

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* 30. How concerned are you here in Hillsdale County with Substance Abuse issues, such as:

  Very Moderately Not at all
Misuse/abuse of prescription drugs
Substance abuse among youth
Substance abuse among adults

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* 31. Are you concerned about your weight?

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* 32. When you think about your weight, do you think you are?

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* 33. In the past year, have you ever had:

  Yes No
Trouble finding a doctor if you need one?
Trouble finding transportation to get to a doctor?
A long wait to get a doctor's appointment?

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* 34. If you had a long wait to get a doctor's appointment, how long a wait was it?

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* 35. How concerned are you, as a resident of Hillsdale County, about:

  Very Moderately Not at all
The availability of healthcare
The quality of healthcare available
The affordability of healthcare available

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* 36. In the past year, have you ever used any of the following services and, if so, was it in Hillsdale County?

  No Yes in Hillsdale County Yes but outside Hillsdale County
Allergist
Cardiologist
Chiropractor
Dentist/Orthodentist
Dialysis
Dietician
Eye Doctor
Foot Doctor
Gastroenterologist
General Practitioner
Neurologist
OB/GYN (if female)
Physical Therapist
Psychologist/Psychiatrist

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* 37. In the past year, have you:

  Yes No Not applicable
Had a flu shot?
Had a pneumonia shot?
Had a colonoscopy?
Been pregnant (if female)
Had a mammogram (if female)
Had a Papp smear (if female)
Had a prostate screening (if male)

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* 38. If you had a baby in the past year, did you use Hillsdale Hospital for the delivery?

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* 39. How many times have you been hospitalized in the past year?

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* 40. If you were hospitalized in the past year, was it at:

  Yes No
Alligance Health
Borgess Hospital
Coldwater Hospital
Hillsdale Hospital
Oaklawn Hospital
Other

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* 41. If you were hospitalized in the past year in the past year but not in Hillsdale, was it because

  Yes No
Services were not available here?
Your doctor does not practice in Hillsdale?
You have a negative impression of Hillsdale?

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* 42. In the past year, have you ever felt:

  Yes No
Depressed (very sad for more than one week)
Suicidal

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* 43. How concerned are you here in Hillsdale County with Environmental issues such as:

  Very Moderately Not at all
Water pollution
Air pollution
Public safety
Crime
Domestic violence
People living in poverty
Affordable housing
Teen pregnancy
Thank you for taking time to participate in the Hillsdale Community Health Assessment Survey on behalf of Hillsdale Hospital.

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