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* 1. Please check three health issues that the hospital should focus. Check up to three.

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* 2. Please answer the following questions based on your personal experience or experience of close family and friends. Indicate how much you agree or disagree with the following statements by selecting 1, 2, or 3.

  Agree Somewhat Agree Disagree
We don’t go to the doctor because hours are NOT convenient.
We don’t have access to health services because there are not enough doctors and nurses.
There are not health specialists in our community for our needs.
Healthy eating and exercise is a challenge for us.
We skip health care because we are afraid to go to the doctor.
It is hard for to make taking care of our health a priority.
Transportation is a barrier for us to get health services.
Cost is one reason we don’t get health services.

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* 3. In addition to the list above, is there anything else that is a barrier to health in our community?

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* 4. Every year, we plan what topics to include in community education programs. What are some topics that you or your family would be interested in attending? (Please list)

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* 5. We want to improve how we get information to people. Please select your top two choices that would like to see (check only 2).

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* 6. Please indicate which of the following would help you get the health services you need?

  Would help a lot  Would help some Would not make a difference
More time at the doctor’s office with a nurse or health educator to discuss my health diagnosis or concerns.
Evening doctor appointments
Weekend doctor appointments
Setting up a payment plan for services
Information on discount prescription programs
Understanding what is covered by my insurance
Low cost health screenings (e.g. mammogram, lab work)
Accepting more insurance (indicate below which insurance you would like us to accept)

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* 7. Which of the following hospital services have you utilized (check all that apply)?

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* 8. Do you need a health service or specialist regularly (weekly, monthly) that is not currently offered at Marlette Regional Hospital?

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* 9. What type of health insurance do you have (check all that apply)?

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* 10. What is your age group?

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* 11. In what county do you live?

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* 12. What is your gender?

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