Sponsored by Coryell Memorial Healthcare System

Question Title

1. How would you rate your personal health?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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)

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

18. How many hours do you sleep each night?

Question Title

19. Best describe your tobacco usage

Question Title

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

Question Title

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

Question Title

22. Where do you get your drinking water?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

35. What is your gender?

Question Title

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

Question Title

37. What is your age?

T