2021 Hancock County Community Health Needs Assessment (CHNA) Please fill out this survey to help us assess the health needs of Hancock County, Illinois. Question Title * 1. What ZIP code do you reside in? Question Title * 2. Gender? Male Female Question Title * 3. What is your race? White Black or African American American Indian or Alaska Native Asian Hispanic or Latino Native Hawaiian & Other Pacific Islander Other Question Title * 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 Yourself 0-35 months Yourself 3-5 years Yourself 6-12 years Yourself 13-17 years Yourself 18-24 years Yourself 25-44 years Yourself 45-54 years Yourself 55-64 years Yourself 65+ Age of Person 2 Age of Person 2 0-35 months Age of Person 2 3-5 years Age of Person 2 6-12 years Age of Person 2 13-17 years Age of Person 2 18-24 years Age of Person 2 25-44 years Age of Person 2 45-54 years Age of Person 2 55-64 years Age of Person 2 65+ Age of Person 3 Age of Person 3 0-35 months Age of Person 3 3-5 years Age of Person 3 6-12 years Age of Person 3 13-17 years Age of Person 3 18-24 years Age of Person 3 25-44 years Age of Person 3 45-54 years Age of Person 3 55-64 years Age of Person 3 65+ Age of Person 4 Age of Person 4 0-35 months Age of Person 4 3-5 years Age of Person 4 6-12 years Age of Person 4 13-17 years Age of Person 4 18-24 years Age of Person 4 25-44 years Age of Person 4 45-54 years Age of Person 4 55-64 years Age of Person 4 65+ Age of Person 5 Age of Person 5 0-35 months Age of Person 5 3-5 years Age of Person 5 6-12 years Age of Person 5 13-17 years Age of Person 5 18-24 years Age of Person 5 25-44 years Age of Person 5 45-54 years Age of Person 5 55-64 years Age of Person 5 65+ Age of Person 6 Age of Person 6 0-35 months Age of Person 6 3-5 years Age of Person 6 6-12 years Age of Person 6 13-17 years Age of Person 6 18-24 years Age of Person 6 25-44 years Age of Person 6 45-54 years Age of Person 6 55-64 years Age of Person 6 65+ Question Title * 5. How long have you lived in Hancock County? Less than a year 1-2 years 3-5 years 6-10 years 11-20 years More than 20 years Question Title * 6. Including yourself, how many members of your household are disabled? 0 1 2 3 or more Question Title * 7. Including yourself, how many adults (age 18 or older) in your household are in fair-to-poor health? 0 1 2 3 or more Question Title * 8. Is any child (age 17 or younger) in your household in fair-to- poor health? Yes, 1 Yes, 2 or more No Not Applicable Question Title * 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) Yes No Question Title * 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). Within the past year Within the past two years Within the past 5 years 5 or more years ago Never Question Title * 11. If your last visit was more than two years ago, is it because you Do not have a medical condition that requires any care Do not routinely receive any health screenings Have scheduling conflicts Could not afford services Do not have or could not arrange transportation I have no insurance coverage I choose not to go Other (please specify) Question Title * 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 doctor/healthcare provider you can go to? Yes Are you aware of a doctor/healthcare provider you can go to? No Are you aware of a dentist you can go to? Are you aware of a dentist you can go to? Yes Are you aware of a dentist you can go to? No Are you aware of a mental health specialist you can go to? Are you aware of a mental health specialist you can go to? Yes Are you aware of a mental health specialist you can go to? No Are you aware of a substance abuse counselor you can go to? Are you aware of a substance abuse counselor you can go to? Yes Are you aware of a substance abuse counselor you can go to? No Are you aware of an eye doctor you can go to? Are you aware of an eye doctor you can go to? Yes Are you aware of an eye doctor you can go to? No Question Title * 13. How many times during the past 12 months have you or any household member used a hospital emergency room? (check only one) None 1-2 times 3-5 times 6 or more times Question Title * 14. If you or a household member used a hospital emergency room in the past 12 months, was it because of: An injury that required immediate attention An injury that did not require immediate attention but it was the most convenient/only service available An ongoing illness An illness that required immediate attention Not Applicable Question Title * 15. Have you or anyone in your household had any difficulty finding a primary doctor/medical provider or specialist within the past two years? Yes No Question Title * 16. If yes to Question 15, briefly, why would you say you had trouble finding a primary doctor/medical provider? Could not get a convenient appointment Did not know how to get in contact with one Provider was not taking new patients No transportation Would not accept your insurance Doctor/Medical provider moved away/retired Not Applicable Other (please specify) Question Title * 17. If yes to Question 15, why were you unable to visit the specialist when you needed one? No appointments were available No specialist was available in this area Did not have transportation to get to the office Could not get to the office while they were open Did not know how to find one Could not afford to pay for the specialist Not Applicable Other (please share what type of specialist you were unable to find) Question Title * 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 Blood Cholesterol Within the past year Blood Cholesterol Within the past 2 years Blood Cholesterol Within the past 5 years Blood Cholesterol 5 years or more Blood Cholesterol Never Blood Cholesterol Not Applicable Colon Cancer Colon Cancer Within the past year Colon Cancer Within the past 2 years Colon Cancer Within the past 5 years Colon Cancer 5 years or more Colon Cancer Never Colon Cancer Not Applicable Diabetes Diabetes Within the past year Diabetes Within the past 2 years Diabetes Within the past 5 years Diabetes 5 years or more Diabetes Never Diabetes Not Applicable Mammogram Mammogram Within the past year Mammogram Within the past 2 years Mammogram Within the past 5 years Mammogram 5 years or more Mammogram Never Mammogram Not Applicable Breast Exam by a medical provider Breast Exam by a medical provider Within the past year Breast Exam by a medical provider Within the past 2 years Breast Exam by a medical provider Within the past 5 years Breast Exam by a medical provider 5 years or more Breast Exam by a medical provider Never Breast Exam by a medical provider Not Applicable Pap Smear Pap Smear Within the past year Pap Smear Within the past 2 years Pap Smear Within the past 5 years Pap Smear 5 years or more Pap Smear Never Pap Smear Not Applicable Prostate Cancer Prostate Cancer Within the past year Prostate Cancer Within the past 2 years Prostate Cancer Within the past 5 years Prostate Cancer 5 years or more Prostate Cancer Never Prostate Cancer Not Applicable Question Title * 19. In your opinion, what are the five (5) most pressing health problems in your community? (check only 5) Ability to pay for care Alcohol – dependency or abuse Drug abuse – prescription medication or illegal substances Cancer Child abuse/neglect Cost of healthcare/and medication Domestic violence Lack of health insurance Lack of transportation to health care services Lack of dental care Lack of eye care Mental health Obesity Teen pregnancy Tobacco use/smoking None Other (please specify) Question Title * 20. In your opinion, what five types of health education services are most needed in your community? (check only 5) Alcohol Abuse Alzheimer’s Disease Asthma Cancer Screening Child Abuse Family Violence Diabetes Nutrition/Diet Physical Activity or Exercise Drug Abuse HIV/AIDS Sexually Transmitted Diseases Smoking Cessation and/or Prevention Stress Management Obesity Mental Health Opioid Abuse Other (please specify) Question Title * 21. What health or community services would you like to see Memorial Hospital and Hancock County Health Department provide? Question Title * 22. What ideas or suggestions do you have for improving the overall health of the community? Question Title * 23. During the past 12 months, have you received a flu shot? Yes No Question Title * 24. If and when the COVID-19 vaccine is available are you interested in receiving the vaccine? Yes No Question Title * 25. During the past month, have you been physically active or exercised, such as running, walking, swimming, golf, etc.? Yes No Question Title * 26. If yes to question 25, how many times a week do you take part in this activity? 1-2 Days 3-4 Days 5-7 Days Answered NO to question 25 Question Title * 27. If yes to question 25, how many minutes or hours each time do you spend doing this activity? Less than 30 minutes 30 minutes to 1 hour 2 hours to 5 hours I answered NO to question 25 Question Title * 28. Do you smoke cigarettes, chew tobacco, or use electronic cigarettes? Yes No If yes, how much on an average day? Question Title * 29. If yes to question 28, are you interested in stopping? Yes No Not Applicable Question Title * 30. I am being treated for? (check all that apply) Adult asthma Angina or Coronary Artery Disease Pneumonia Cancer CHF (Congestive Heart Failure) COPD (Chronic Obstructive Pulmonary Disease) Diabetes or High Blood Sugar Heart Attack High Cholesterol Hypertension (High Blood Pressure) Stroke Overweight or Obesity Not Applicable If you said yes to Cancer, what type? Question Title * 31. Has a child in your household (age 17 or younger) been told they have one of the following conditions? (check all that apply) Asthma Diabetes Overweight or Obesity Cancer None I do not have children Other health condition (please specify) Question Title * 32. Has a child in your household (age 17 or younger) used the following? (check all that apply) Alcohol Marijuana Methamphetamine Opioids Heroin Tobacco Not applicable Other (please specify) Question Title * 33. What is your highest level of education? Elementary school Left high school without a diploma High School diploma GED Currently attending or have some college Two-year college degree Four-year college degree Graduate-level degree or higher Question Title * 34. Including yourself, how many adults in your household are retired? None 1 2 3 4 or more Question Title * 35. Including yourself, how many adults (age 18 years or older) in your household are employed full time, year-round? None 1 2 3 4 or more Question Title * 36. Including yourself, how many adults (age 18 years or older) are unemployed? None 1 2 3 4 or more Question Title * 37. How many household members are currently covered by health insurance? Number of adults (18 and older) covered by health insurance: Number of children (17 and under) covered by health insurance: Number of household members not covered by insurance: Question Title * 38. If you and/or members of your household have health insurance coverage, how is it obtained? (check all that apply) Medicare Medicaid Through a retirement insurance plan Though an employer’s health insurance plan Veterans’ Administration Privately purchased Other (please specify) Question Title * 39. Do any of these insurance policies provide dental coverage? Yes No Question Title * 40. Do any of these insurance policies provide vision coverage? Yes No Question Title * 41. Do any of these insurances pay for prescription drugs? Yes, with co-payment Yes, with no co-payment No I am unsure Question Title * 42. What hospital do you use? Question Title * 43. How do you choose a hospital to receive care? Closest My provider is there Insurance Coverage Other (please specify) Question Title * 44. What was the combined household income last year? (check only one) Less than $20,000 $20,000 - $49,999 $50,000 - $69,999 $70,000 - $99,999 $100,000 - or more Question Title * 45. How would you describe your housing situation? (check only one) Own a house or condo Rent a house, apartment or room Living in a group home Living temporarily with a friend or relative Multiple households sharing an apartment or house Living in a shelter Living in a motel Living in senior housing or assisted living Homeless Other (please specify) Done
