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Evergreen Medical Center - Community Health Needs Assessment
1.
E-mail Address
*
2.
Do you make the majority of the healthcare decisions in your household, such as which hospitals and doctors to use for medical care?
(Required.)
Yes
No
*
3.
What is the zip code you live in?
(Required.)
*
4.
My age
(Required.)
18-29
30-49
50-64
65-84
85+
*
5.
I am
(Required.)
Male
Female
*
6.
What type of health insurance coverage do you have?
(Required.)
I have health insurance sponsored by my employer (Blue Cross, Managed Care, etc.)
I have health insurance covered by Medicaid
I have health insurance covered by Medicare
I have health insurance but do not know with whom
I don't have health insurance
I don't know if I have health insurance
*
7.
My race
(Required.)
Asian or Pacific Islander
Black or African American
Hispanic
Inter-racial
Native American
White or Caucasian
*
8.
Employment Status
(Required.)
Full-Time
Part-Time
Unemployed
Student
Retired
*
9.
My annual household income
(Required.)
less than $50,000
$50,000 - $100,000
over $100,000
*
10.
What is your highest level of education completed?
(Required.)
Some High School
High School/GED
Some College
College-Undergraduate
College - Graduate
Post-Graduate
*
11.
Do you have children under the age of 18 living with you?
(Required.)
Yes
No
*
12.
Do you have elderly relative(s) living with you?
(Required.)
Yes
No
*
13.
What do you consider your current health status to be?
(Required.)
Excellent
Good
Fair
Poor
*
14.
Where do you go for routine healthcare?
(Required.)
Family Physician's Office
Hospital Emergency Room
Health Department
Medical/Urgent Care
I don't seek healthcare
Other (please specify)
*
15.
Have you had a physical examination by your physician in the past year?
(Required.)
Yes
No
*
16.
Do you consider your weight to be?
(Required.)
Underweight
About Right
Overweight
*
17.
Select any of the following with which you have been diagnosed:
(Required.)
Diabetes
High Blood Pressure
Cholesterol
Cardiovascular (Heart) Disease
Respiratory Disease (Asthma, etc.)
Chronic Pain (Back, Arthritis, etc.)
None
Other (please specify)
*
18.
Have you been diagnosed with cancer in the past five (5) years?
(Required.)
Yes
No
*
19.
Have you been a patient in the Emergency Room in the past year?
(Required.)
Yes
No
*
20.
Have any of your dependents been in an Emergency Room in the past year?
(Required.)
Yes
No
*
21.
Did a lack of transportation prevent you from receiving medical care in the past year?
(Required.)
Yes
No
*
22.
Did the cost of care prevent you from receiving medical care in the past year?
(Required.)
Yes
No
*
23.
Do you smoke or use smokeless tobacco?
(Required.)
Yes
No
24.
Does anyone in your home smoke?
Yes
No
*
25.
If you are a woman over the age of 40, have you had a mammogram in the past year?
(Required.)
Yes
No
Not Applicable
*
26.
If you are a woman over the age of 21, have you had a Pap smear in the past year?
(Required.)
Yes
No
Not Applicable
*
27.
If you are employed, did you miss more than ten (10) days of work last year due to illness?
(Required.)
Yes
No
Not Applicable
*
28.
Do you routinely exercise?
(Required.)
Yes
No
*
29.
Do you routinely use the stairs instead of riding the elevator?
(Required.)
Yes
No
*
30.
When parking your car, do you try to park in the nearest parking space to the door?
(Required.)
Yes
No
*
31.
Do you suffer from depression?
(Required.)
Yes
No
*
32.
Have you been diagnosed with a mental illness?
(Required.)
Yes
No
*
33.
Do you drink alcohol daily?
(Required.)
Yes
No
*
34.
Do you use sunscreen when you are out in the sun for an extended period of time?
(Required.)
Yes
No
*
35.
Do you use a seatbelt when you are driving or traveling in a car?
(Required.)
Yes
No
*
36.
How many servings of fruits and vegetables do you eat each day?
(Required.)
1-2
3-4
5+
None
*
37.
In your opinion, please select three (3) items below that represent the most important health issues in our community:
(Required.)
Access to medical care
Cost of Care
Use of illegal drugs
Mental Health Issues (including Dementia and related conditions)
Heart and Stroke (Blood Pressure)
Obesity and related issues
Diabetes
Use of Tobacco Products
Sexually Transmitted Diseases (STD's)
Children's Illnesses
Cancer and Related Illnesses
Other (please specify)
*
38.
If you needed hospital care, which hospital in the area would you prefer to use?
(Required.)
*
39.
In the past year, have you or has any member of your household spent one night or more as a hospital inpatient (admitted to the hospital for one or more nights)?
(Required.)
Yes
No
*
40.
Which hospital did you or your household stay in during that most recent stay?
(Required.)
*
41.
Using any number from 0-10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during the stay?
(Required.)
*
42.
Which of the following best describes how the decision was made to use that hospital?
(Required.)
A doctor recommended or referred the patient there
The patient and/or family selected the hospital on their own, without a doctor's recommendation
Referral
The patient's health insurance plan specified which hospital was to be used
It was an emergency situation and no choice was involved
Other (please specify)
43.
(Optional) Please write any comments that you would like to make:
