Geary Community Hospital and Live Well Geary County are working together to provide this community wide survey. The hospital is 
conducting a Community Health Needs Assessment and Live Well Geary County is conducting a survey to gather your understandings about opportunities for physical activity, healthy eating, and tobacco
cessation in your community. This survey will also help better
understand the health needs of our community. The information
gathered will ensure that our community have healthy options to
choose from and help determine the future Pathways to a Healthy
Kansas Initiatives.

Your responses will be compiled with other responses and will
never directly identify your individual response. We are gathering
some demographic information to ensure that we have gathered
feedback from a broad representation of individuals in the
community, but this will not be shared outside the project team. You
can choose to skip questions that you don’t feel comfortable
answering and you can stop at any time.

We thank you for your participation!

* 1. What is your zip code?

* 2. What is your age?

* 3. Your gender?

* 4. How would you best describe your culture/ethnicity?

* 5. Are you:

* 6. What was the highest level of education that you completed in school?

* 7. How long have you lived in the Junction City / Geary County area?

* 8. How many people live in your household?

* 9. Is anyone in your household military or retired military?

* 10. Does anyone in your household receive benefits from the military?

* 11. I would say my health is

* 12. Compared to a year ago, how would you rate your overall health in general now? 

* 13. Types of health insurance I have:

* 14. In the past year have you or someone in your household lost health insurance coverage? 

* 15. If yes, was this due to:

* 16. How much moderately intense (or greater) physical activity do you get each week?

* 17. Do you...

  Yes No
Eat "right"
Use tobacco products
Excessively consume alcohol (Excessive - More than 4-5 drinks in one day, more than 5 times per month)

* 18. Where do you usually go for your primary healthcare?

* 19. If you use the hospital emergency room for your healthcare, why?

* 20. If your doctor/provider is in Geary County: Are you able to get an appointment within 48 hours with him/her?

* 21. If your doctor/provider is in Geary County: How satisfied are you with your visits?

* 22. If your doctor/provider is in Geary County: Do you feel your primary care doctor/provider spends enough time with you?

* 23. The last time I...

  Less than 1 year ago 1-2 years ago 2-5 years ago 5+ years ago Never
Visited a doctor for a routine checkup was...
Had a dental exam and/or teeth cleaning was...
Had a cholesterol screening was...
Had a colorectal cancer screening was...
Had a blood pressure screening...
(if you are male) had a prostate screening was...
(if you are female) had a breast exam by a healthcare provider was...
(if you are female) had a mammogram was...
(if you are female) had a pap smear (a test for cervical cancer) was...

* 24. In the past 12 months have you missed one or more healthcare appointments because you did not have transportation?

* 25. Have you delayed any of the following due to lack of money and/or insurance?

  Yes No
Visiting a doctor?
Visiting a dentist?
Filling a prescription?
Buying eyeglasses?
Buying medical supplies?
Getting an x-ray or lab test?

* 26. Have you or someone in your household used inpatient hospital services (been admitted) in the past 2 years?

* 27. At which hospital were services received?

* 28. Within the last 2 years, what services have you or your family used at Geary Community Hospital?

* 29. How satisfied were you with those services?

* 30. After considering the services offered by Geary Community Hospital, what services are not available that you believe would be beneficial?

* 31. What specialists have you or someone in your household used in the past 2 years? Specialists are physicians/providers who are trained in specific areas (i.e. allergy, orthopedics, cardiology, gastroenterology, urology)

* 32. Please list the clinic and city where you saw each specialist.

* 33. Did the specialist request further testing, laboratory work, and/or x-rays?

* 34. If yes, in what facility were the tests or laboratory work performed? 

* 35. What ways do you think the community can help you to better manage your own health (stop smoking, nutritional information, exercising)? 

* 36. Where do you generally get your health information?

* 37. Do you know where to go for...

  Yes No
Eldercare in your family?
Mental health services?
Home care services?
Financial assistance for your healthcare?

* 38. In general how would you rate the overall quality of the healthcare delivered to our community?

* 39. What additional services, if any, would you like to see offered to residents to help them manage their own health?

* 40. In your opinion, what areas need additional education or attention in our community?

* 41. What concerns you most about health, healthcare, and healthy living in Geary County? 

* 42. In general, how would you rate the overall health of our community?

* 43. If you said "Unhealthy" or "Very unhealthy" please tell us why:

* 44. During the past four weeks...

  All of the time Most of the time Sometimes None of the time
My physical health or emotional problems interfered with my social activities (like visiting friends, relatives, etc.)
I was limited in my work or other activities as a result of my poor physical health.
Pain interfered with my normal work.

* 45. How much exercise / physical activity do you get in a day?

* 46. What are some of the reasons keeping you from taking part in exercising/physical activity?

* 47. Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
My community has enough sidewalks or bike/walk paths.
My community has a sufficient number of parks/playgrounds
For walking at night, my community has adequate street lighting
In general, my community has sufficient opportunities for physical activity

* 48. How many cups of fruits or vegetables do you eat in a day?

* 49. What are some of the barriers to achieving the recommended servings of fruits and vegetables?

* 50. Please rate your level of agreement with the following statements:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
It is easy to find fresh fruits and vegetables in my community.
The fresh produce in my community is of high quality.
It is easy to find whole grain products, such as breads, cereals, pasta and snacks, in my community.
In general, my community has sufficient options for healthy eating.

* 51. Are you aware of efforts in your community to promote smoking cessation (i.e. quitting smoking)?

* 52. Please rate your level of support for raising the minimum age for tobacco purchases from the current age (18) to 21 years of age?

* 53. Please rate your level of support for policies that prohibit tobacco use (i.e. smoking and chewing tobacco) in the following settings:

  Definitely not supportive Not supportive Neutral Supportive Very supportive
Local parks
School grounds
Hospital grounds
Work sites

* 54. Would you vote for a policy that bans smoking in a vehicle with a child under the age of 15?

* 55. If you are a smoker or use tobacco and desire to stop...

  Yes No  I'm a non-smoker
Have you tried to stop at least once?
Do you know of at least one agency/organization to go to help to stop?

* 56. Were you aware of the Pathways to a Healthy Kansas Initiative that is being implemented by Live Well Geary County in your community?

* 57. Where / how you got this survey: (check one)

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