Sponsored by Coryell Memorial Healthcare System

1. How would you rate your personal health?

2. How would you rate the overall health of Coryell County?

3. Where do you look for information about health resources in Coryell County?

4. Where do usually go when you are sick or need primary health care (Family Practice)?

5. Within the past year, what MENTAL health services did you or your family member use in Coryell County?

6. If you or a family member needed long term care placement (nursing home care), was it available in Coryell County?

7. Has a healthcare provider ever told you that you have any of the following health problems (check all that apply)

8. If your primary care provider has referred you to a specialist within the past 2 years, where did you go for specialty care? (ex Gastroenterology, Cardiovascular Surgery, ENT, General Surgery, etc)

9. What types of specialists have you seen in the past 2 years?

10. What are the top 4 behaviors that have the most negative impact in Coryell County (select no more than 4)?

11. What do you think are the 5 most important health problems in Coryell County (Select 5)

12. When is the last time that you:

  Never Past Year 2 - 4 Years 5 years or more
Visited a dental clinic
Had an eye exam
Had a flu shot
Had your cholesterol check
Had a skin cancer check
Had a blood sugar test (diabetes)
Had a routine check up

13. Do you think having a hospital in your community is important?

14. What are the barriers to getting healthcare in your community?

15. For WOMEN, when was the last time you had a mammogram?

16. For MEN, when was the last time you had a prostate specific antigen test (PSA for prostate cancer - lab test)

17. About how many alcoholic drinks do you have each week?

18. How many hours do you sleep each night?

19. Best describe your tobacco usage

20. In the past 7 days, how many times did you eat out at restaurants?

21. Do you support NO smoking for indoor public buildings in your current city or residence?

22. Where do you get your drinking water?

23. About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?

24. Have you had a sunburn within the past 12 months?  Including any time that your skin was red for more than 12+ hours)

25. What is your health care coverage? (Check all that apply)

26. Why do you currently not have health insurance IF you are not insured? (Check all that apply)

27. Does your household CURRENTLY use any of the following home security services?

28. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

29. In the past 12 months, have you been unable to do the following because of cost?

30. Which of the following best describes your current relationship status?

31. Which of the following categories best describes your employment status?

32. How many people currently live in your household, including yourself?

33. Do you or anyone in your household prefer to use a language other than English?

34. Do you or anyone in your household receive any of the following (check all that apply)

35. What is your gender?

36. What is your ethnicity? (Please select all that apply.)

37. What is your age?

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