PATRICK COUNTY COMMUNITY HEALTH SURVEY

The Patrick County Coalition is working with leaders in the area to learn more about your health care needs. This is being done to improve health care issues in the County and to obtain funds for this purpose. Please answer the following questions with the best answer or answers. All surveys will be kept confidential. Thank you for taking the time to complete this survey. Questions about the survey may be addressed to: nancy.bell@vdh.virginia.gov. Please complete the survey only once!

* 1. Is there a specific doctor’s office, health center, or other place that you usually go if you are sick or need advice about your health? (Skip to Question 5 if the answer is "no")

* 2. Is this where you would go for new health problems?

* 3. Is this where you would go for preventive health care, such as general check-ups, examinations and immunizations (shots)?

* 4. Is this where you would go for referrals to other health professionals when needed?

* 5. Do you use medical care services?

* 6. If yes, where do you go for medical care? (Check all that apply)

* 7. Do you use dental care services?

* 8. If yes, where do you go for dental care? (Check all that apply)

* 9. Do you use mental health, alcohol abuse, or drug abuse services?

* 10. If yes, where do you go for mental health, alcohol abuse or drug abuse services? (Check all that apply)

* 11. What do you think are the 5 most important issues that affect health in our community? (Please check 5)

* 12. Are you a resident of Patrick County?

* 13. Which health care services are hard to get in our community? (Check all that apply)

* 14. What do you feel prevents you from getting the healthcare you need? (Check all that apply)

* 15. I have had an eye exam within the past 12 months

* 16. I have had a mental health /substance abuse visit within the past 12 months

* 17. I have had a dental exam within the past 12 months

* 18. I have been to the emergency room during the past 12 months

* 19. I have been to the emergency room for an injury in the past 12 moths (motor vehicle crash, fall, poisoning, burn, cut, etc.)

* 20. I have been the victim of domestic violence or abuse during the past 12 months

* 21. My doctor has told me that I have a long-term or chronic illness

* 22. I take the medicine my doctor tells me to take to control my chronic illness

* 23. I can afford medicine needed for my health conditions

* 24. I am over 21 years of age and have had a Pap smear in the past three years (if male or under 21, please check not applicable)

* 25. I am over 40 years of age and have had a mammogram in the past 12 months (if male or under 40, please check not applicable)

* 26. I am over 50 years of age and have had a colonoscopy in the past 10 years (if under 50, please check not applicable)

* 27. Does your neighborhood support physical activity? (parks, sidewalks, bike lanes, etc.)

* 28. Does your neighborhood support healthy eating? (community gardens, farmers' markets, etc.)

* 29. In the area you live, is it easy to get affordable fresh fruits and vegetables?

* 30. Have there been times in the past 12 moths when you did not have enough money to buy the food that you and your family needed?

* 31. Where do you get the food that you eat at home? (Check all that apply)

* 32. How many times in the past year were you unable to see a medical provider due to lack of available appointments?

* 33. During the past 7 days, how many times did you eat fruit or vegetables (fresh or frozen)? Do not count fruit or vegetable juice. 

* 34. Have you been told by a doctor that you have... (Check all that apply)

* 35. How long has it been since you last visited a doctor for a routine checkup? 

* 36. How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.

* 37. In the past 7 days, on how many days were you physically active for a total of at least 30 minutes? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard for some of the time.)

* 38. Other than your regular job, what physical activity or exercises do you participate in? (Check all that apply)

* 39. In the past 7 days, how many times did all, or most of, your family living in your house eat a meal together?

* 40. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

* 41. Thinking about your mental health, which includes physical illness and injury, for how many days during the past 30 days was your mental health not good?

* 42. During the last 30 days, how many days did you miss work or school due to pain or illness (physical or mental)?

* 43. During the past 30 days: (Check all that apply)

* 44. Have you ever used heroin?

* 45. If you do not drive, what mode of transportation do you typically use?

* 46. What types of information help you learn the best about your health care? (Check all that apply)

* 47. Which of the following describes your current type of health insurance? (Check all that apply)

* 48. If you have no health insurance, why don't you have insurance? (Check all that apply)

* 49. What is your ZIP code?

* 50. What is your street address? (Optional)

* 51. What is your age?

* 52. What is your gender?

* 53. What is your height?

* 54. What is your weight?

* 55. How many people 0-17 years of age live in your home (including yourself)?

* 56. How many people 18-64 years of age live in your home (including yourself)?

* 57. How many people 65 years of age or older live in your home (including yourself)?

* 58. What is your highest educational level completed?

* 59. What is your primary language?

* 60. Which ethnicity do you identify with? (Check all that apply)

* 61. What is your marital status?

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50% of survey complete.

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