Section I: Introduction
In this survey, we are trying to identify the healthcare needs of residents or workers in the areas of Roslindale, West Roxbury, and Hyde Park. This work is done by the Greater Roslindale Medical & Dental Center, part of the Boston Medical Center. This information will be used to plan for future services and programs. 

Filling out this survey is voluntary, and your responses are anonymous. You will not be asked for your name, address, or any information that can be used to identify you unless you so choose to. This survey will take approximately 5 minutes to complete. Your input is very valuable. It helps make sure that future plans meet different community and resident needs. 

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* 1. What is your age?

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* 2. What gender do you identify as?

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* 3. Which of these groups best represents your race (Please check all that apply)

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* 4. Do you have any children?

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* 5. Which Zipcode do you live in?

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* 6. Which Zipcode do you work in?

Section II: Access to Healthcare

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* 7. When you are sick or need advice about your health, which of the following places do you usually go? (Please check all that apply)

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* 8. From the following list, what are your top 5 most important health concerns concerning you or your family?

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* 9. When was the last time you had a dental check-up?

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* 10. In the last year, which medical services have you used

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* 11. Was there a time in the past 12 months when you needed to see a doctor or a dentist but could not?

Section III: Familiarity with the Greater Roslindale Medical & Dental Center (GRMDC)

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* 12. Have you heard of the Greater Roslindale Medical and Dental Center (GRMDC)

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* 13. If Yes, are there services at the Greater Roslindale Medical & Dental Center that you would like to receive and currently don’t?

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* 14. Which 3 factors are most important to you in choosing a health services provider?

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* 15. What 3 factors would cause you to look for a new health services provider?

End of Survey - Thank you for your help!

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