Question Title

* 1. What county do you live in?

Question Title

* 2. What is the source of your health insurance coverage?

Question Title

* 3. What is your current employment status?

Question Title

* 4. What is your highest level of education?

Question Title

* 5. Which best describes your field?

Question Title

* 6. What is your total yearly household income?

Question Title

* 7. I am

Question Title

* 8. What was your age on your last birthday?

Question Title

* 9. My racial/ethnic identification is:

Question Title

* 10. Are you a smoker? (results will be kept confidential)

Question Title

* 11. What are the top health challenges you face? (Choose all that apply)

Question Title

* 12. What do you feel are the biggest health concerns in your community? (Select all that apply)

Question Title

* 13. What do you think stops people in your community from seeking medical care? (Select all that apply)

Question Title

* 14. What do you think most affects the quality of health care you or others in your community receive? (Select all that apply)

Question Title

* 15. What do you feel people in your community lack the ability to purchase most?

Question Title

* 16. How would you rate your personal health?

Question Title

* 17. What should your community focus on to improve its health? (Check all that apply)

Question Title

* 18. What health screenings, education, or free services are needed in your community?

Question Title

* 19. Where do you or your family get health information? Check all that apply:

Question Title

* 20. Where do you go for routine medical care? Check all that apply:

Question Title

* 21. How do you access your health care?

Question Title

* 22. Have you or someone in your household delayed health care due to lack of money and/or insurance?

Question Title

* 23. Are you able to get an appointment with your primary care (family) doctor, physician assistant or nurse practitioner in the service area of Coffee Regional Medical Center when you need one?

Question Title

* 24. Have you or someone in your household used medical services of Coffee Regional Medical Center in the past 24 months?

Question Title

* 25. Why did you or your family member choose Coffee Regional Medical Center? Check all that apply:

Question Title

* 26. What services were used? Check all that apply:

Question Title

* 27. How satisfied were you or someone in your household with the quality of physician care (or physician assistant or nurse practitioner) received in the service area of Coffee Regional Medical Center? (On a scale of 1 to 5)

i We adjusted the number you entered based on the slider’s scale.

T