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* 1. Please check your postal code.

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* 2. Are you:

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* 3. What is your age?

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* 4. When you are greeted at reception or spoken to on the phone is the staff sensitive to your needs and are you treated with dignity and respect?

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* 5. Thinking back to within the past year or the last time you were sick or concerned you had an urgent health problem, how many days did it take to book an appointment with a Primary Care practitioner to when you were actually seen. (To clarify, this appointment does not have to be with your physician but rather you were offered an appointment with another practitioner such as a Doctor, Nurse Practitioner, Physician Assistant or Registered Practical Nurse)

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* 6. When you see your Dr. or Nurse practitioner, how often do they or someone else in the office involve you as much as you want to be in decisions about your care and treatment?

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* 7. If you are a client aged 50-74 years of age. Have you had a fecal occult blood test for bowel cancer screening within past two years, or sigmoidoscopy or barium enema within five years, or a colonoscopy within the past 10 years

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* 8. If you are woman aged 21-69 years of age have you had a Pap test within the past 3 years as part of Cancer prevention screening?

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* 9. If you have diabetes and are aged 40 or older have you had two or more glycated hemoglobin (HbA1C) tests within the past 12 months?

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* 10. If you need care after hours in this area where do you go? (Choose all that apply)

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* 11. Overall how would you rate the care you received at the Grand Bend Area CHC?

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* 12. I always feel comfortable and welcomed at the Grand Bend Area CHC

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* 13. How would you describe your sense of belonging (feeling connected) to your community?

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* 14. How often do you feel uncomfortable or out of place in your community?

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* 15. Was this feeling of discomfort related to any of the following (Choose all that apply):

Questions 16, 17, 18 are related to the social contact you have.

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* 16. I am content with my friendships and relationships

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* 17. I have enough people I feel comfortable asking for help any time.

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* 18. I often feel isolated and lonely.

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* 19. In general, would you say your physical health is:

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* 20. In general, would you say your mental health is:

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* 21. How much time do you spend in physical leisure activities in a typical week (example walking, gardening, exercise class or playing a sport)

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* 22. How many pieces or servings of fruit and vegetables do you eat in a day? (Fresh, canned or frozen)

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* 23. Do you face barriers to accessible reliable transportation?

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* 24. In the last year which services or providers have you seen? (Choose all that apply:)

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* 25. If you were not able to attend an appointment with a provider or a group session, what got in the way? (Choose all that apply)

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* 26. Do you smoke

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* 27. If you answered yes, would you be interested in help in quitting (Please contact us)

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* 28. I drink alcohol

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* 29. Are you aware that the Health Centre has an addictions counselor available on site to help with gambling, drug and/or alcohol dependencies.

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* 30. How did you hear about the Centre's programs and services? (Check all that apply)

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* 31. In the past 12 months have you done any of the following to improve your health as a result of services received by GBACHC?

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* 32. Is there anything stopping you from making this change or improvement (Click all that apply)

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* 33. Please check on any program you would be interested in attending related to the following.

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* 34. When is the best time to schedule programs sessions? (Choose all that apply)

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* 35. Where would you like programs to be located? (Choose all that apply)

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* 36. How often during the past year did you have difficulty making ends meet (for example, buying food, making a rent or mortgage payment, paying bills, or having enough money for childcare or transportation)?

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* 37. How would you describe your level of stress? 

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* 38. How do you deal with your stress? (Choose all that apply)

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* 39. What factors affect your level of stress the most? (Choose all that apply)

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* 40. Please comment on any GBACHC Programs and/or Services.

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