Hallmark Health Community Health Survey 2010 1. Default Section Question Title * 1. Please enter your age (Required.) Question Title * 2. In what city or town do you live? (Required.) Burlington Everett Malden Medford Melrose North Reading Reading Saugus Stoneham Wakefield Wilmington Winchester Other (please specify) Question Title * 3. In what city or town do you work? Burlington Everett Malden Medford Melrose North Reading Reading Saugus Stoneham Wakefield Wilmington Winchester Other (please specify) Question Title * 4. How many people live in your household? Please count yourself as one. (Required.) 1 2 3 4 5 6 7 8 9 10 Other Other (please specify) Question Title * 5. Do you have a primary care provider? (Required.) Yes No Other (please specify) Question Title * 6. If you do not have a primary care provider, do you need help in choosing one? (Required.) Yes No Other (please specify) Question Title * 7. Where do you receive your regular health services? (Required.) Lawrence Memorial Hospital- Hallmark Health Melrose-Wakefield Hospital- Hallmark Health Massachusetts General Hospital Mt. Auburn Hospital Lahey Clinic Burlington Lahey Clinic Peabody Winchester Hospital Beth Israel Deaconess Medical Center Tufts Medical Center Cambridge Hospital Whidden Hospital Brigham and Women's Hospital Other Other (please specify) Question Title * 8. Where do you receive Emergency Services? (Required.) Lawrence Memorial Hospital- Hallmark Health Melrose-Wakefield Hospital- Hallmark Health Massachusetts General Hospital Mt. Auburn Hospital Lahey Clinic Burlington Lahey Clinic Peabody Winchester Hospital Beth Israel Deaconess Medical Center Tufts Medical Center Cambridge Hospital Whidden Hospital Brigham and Women's Hospital Other Other (please specify) Question Title * 9. Are there any issues that keep you and your family from seeking health care? Please chose all that apply. Transportation Large co-payments Lack of Health Insurance Other Understanding the language(s)spoken Hours of operation Disability Medical debt Other (please specify) Question Title * 10. What are your top three health concerns? (Required.) Question Title * 11. What could Hallmark Health do to help you or your family to receive better health care? (Required.) Question Title * 12. Do you have any comments for us? Question Title * 13. What is the highest level of education you're reached? Elementary School Middle School High School Jr. College 4-year College Masters Degree Doctoral Degree Other (please specify) Question Title * 14. What is your income range? 0 to $25,000 $25,000 to $35,000 $35,000 to $50,000 $50,000 to $70,000 $70,000 and up Question Title * 15. What is your race? American Indian Asian Black Native American Pacific Islander White Other (please specify) Question Title * 16. What language(s) do you speak at home? Please check all that apply. English Spanish Portuguese Vietnamese Italian Haitian Creole Cantoneses Mandarin Other (please specify) Question Title * 17. What is your gender? Male Female Please comment Question Title * 18. What is your ethnicity? Hispanic Non-Hispanic Other (please specify) Question Title * 19. How would you rate your current health status? (Required.) Excellent Good Fair Poor Other (please specify) Question Title * 20. Please complete the following information: Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Country: Email Address: Phone Number: Thank you for completing this survey. The information you share will be used in planning future Community Benefits programs and to improve overall health services. Done