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* 1. What county do you live in?

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

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* 3. What is your current employment status?

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* 4. What is your highest level of education?

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* 5. Which best describes your field?

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* 6. What is your total yearly household income?

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* 7. I am

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

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* 9. My racial/ethnic identification is:

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

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

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

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

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

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

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* 16. How would you rate your personal health?

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

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

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

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

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* 21. How do you access your health care?

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

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* 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?

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

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

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

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* 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)

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