Please fill out this survey to help us assess the health needs of Hancock County, Illinois.

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* 1. What ZIP code do you reside in?

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* 2. Gender?

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* 3. What is your race?

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* 4. What are the ages of the people who live in your household?

  0-35 months 3-5 years 6-12 years 13-17 years 18-24 years 25-44 years 45-54 years 55-64 years 65+
Yourself
Age of Person 2
Age of Person 3
Age of Person 4
Age of Person 5
Age of Person 6

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* 5. How long have you lived in Hancock County?

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* 6. Including yourself, how many members of your household are disabled?

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* 7. Including yourself, how many adults (age 18 or older) in your household are in fair-to-poor health?

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* 8. Is any child (age 17 or younger) in your household in fair-to- poor health?

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* 9. Are you or any household member a PRIMARY caregiver for an aged, disabled or chronically ill person? (including a parent, spouse or other relative)

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* 10. When was your last visit to the doctor for a routine check-up? (A routine check-up is a general visit, not for a specific injury, illness, or condition).

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* 11. If your last visit was more than two years ago, is it because you

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* 12. If you or a household member have a health care need:

  Yes No
Are you aware of a doctor/healthcare provider you can go to?
Are you aware of a dentist you can go to?
Are you aware of a mental health specialist you can go to?
Are you aware of a substance abuse counselor you can go to?
Are you aware of an eye doctor you can go to?

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* 13. How many times during the past 12 months have you or any household member used a hospital emergency room? (check only one)

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* 14. If you or a household member used a hospital emergency room in the past 12 months, was it because of:

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* 15. Have you or anyone in your household had any difficulty finding a primary doctor/medical provider or specialist within the past two years?

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* 16. If yes to Question 15, briefly, why would you say you had trouble finding a primary doctor/medical provider?

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* 17. If yes to Question 15, why were you unable to visit the specialist when you needed one?

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* 18. About how long has it been since you had the following tests/screening done?

  Within the past year Within the past 2 years Within the past 5 years 5 years or more Never Not Applicable
Blood Cholesterol
Colon Cancer
Diabetes
Mammogram
Breast Exam by a medical provider
Pap Smear
Prostate Cancer

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* 19. In your opinion, what are the five (5) most pressing health problems in your community? (check only 5)

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* 20. In your opinion, what five types of health education services are most needed in your community? (check only 5)

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* 21. What health or community services would you like to see Memorial Hospital and Hancock County Health Department provide?

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* 22. What ideas or suggestions do you have for improving the overall health of the community? 

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* 23. During the past 12 months, have you received a flu shot?

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* 24. If and when the COVID-19 vaccine is available are you interested in receiving the vaccine?

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* 25. During the past month, have you been physically active or exercised, such as running, walking, swimming, golf, etc.?

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* 26. If yes to question 25, how many times a week do you take part in this activity?

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* 27. If yes to question 25, how many minutes or hours each time do you spend doing this activity?

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* 28. Do you smoke cigarettes, chew tobacco, or use electronic cigarettes?

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* 29. If yes to question 28, are you interested in stopping?

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* 30. I am being treated for? (check all that apply)

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* 31. Has a child in your household (age 17 or younger) been told they have one of the following conditions? (check all that apply)

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* 32. Has a child in your household (age 17 or younger) used the following? (check all that apply)

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* 33. What is your highest level of education?

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* 34. Including yourself, how many adults in your household are retired?

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* 35. Including yourself, how many adults (age 18 years or older) in your household are employed full time, year-round?

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* 36. Including yourself, how many adults (age 18 years or older) are unemployed?

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* 37. How many household members are currently covered by health insurance?

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* 38. If you and/or members of your household have health insurance coverage, how is it obtained? (check all that apply)

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* 39. Do any of these insurance policies provide dental coverage?

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* 40. Do any of these insurance policies provide vision coverage? 

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* 41. Do any of these insurances pay for prescription drugs?

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* 42. What hospital do you use?

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* 43. How do you choose a hospital to receive care?

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* 44. What was the combined household income last year? (check only one)

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* 45. How would you describe your housing situation? (check only one)

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