Hello,
Health departments, hospitals, county health plans and the Northern Michigan Health Network are working together to find out what the most important health issues are in Northern Michigan. One important part of the project is this Community Survey. Your input is very important! Your opinions will help us decide what to work on across the region for the next 3 years.
Thank you!

* 1. Please check the THREE most important factors needed for a healthy community.

* 2. Please check the THREE most important community health problems in your county.

* 3. Please check all the problems adults, older adults, and children in your family are having in getting health care services.

  Adults Older adults Children
Cannot afford visits to doctor,clinic, and/or hospital
Cannot find doctor to take me as a patient
Difficult to set appointments
Do not know where to go for health care
ER waiting time
Finding a behavioral health provider
Finding a dentist
Finding a doctor
Getting pregnancy care
Getting specialist care
Health insurance coverage is limited
Health insurance does not cover behavioral health services
Health insurance does not cover dental services
Health insurance does not cover medications
Health insurance has high deductibles and/or copays
Lack of health insurance
Physician dropped me as a patient for missing appointments
Too busy to get to doctor
Transportation issues

* 4. Have you or any member of your immediate family ever been told by a doctor or other health professional that you have any of the following? Check all that apply.

  You Member of your immediate family
Alcoholism or other addiction
Arthritis
Asthma
Cancer
Chronic pain
Dental health problems
Diabetes/prediabetes
Hearing problems
Heart disease/heart attack
High blood pressure
High cholesterol
Kidney disease
Lung disease/COPD
Overweight/Obese
Stroke

* 5. How long has it been since your most recent visit /care experience?

* 6. Where was your most recent visit/care experience?

* 7. How many visits have you had with this provider?

* 8. Do you have a primary care/family physician?

* 9. Following is a series of characteristics which may describe your health care visit. Please indicate how important the characteristic is to you.

  Very important Somewhat important Neither Important nor Unimportant Somewhat Unimportant Very Unimportant
Health Care Provider/Physician expresses understanding of my personal values when considering my care decisions
Health Care Provider/Physician shows respect for my opinions
Health Care Provider/Physician helps me to understand options available for treatment
Health Care Provider/Physician involves me in decision-making about my care
Health Care Provider/Physician spends enough time with me to discuss options and questions

* 10. How would you rate your most recent visit/care experience with regard to each characteristic?

  Excellent Above Average Average Below Average Poor
Health Care Provider/Physician expresses understanding of my personal values when considering my care decisions
Health Care Provider/Physician shows respect for my opinions
Health Care Provider/Physician helps me to understand options available for treatment
Health Care Provider/Physician involves me in decision-making about my care
Health Care Provider/Physician spends enough time with me to discuss options and questions

* 11. Please consider your most recent health care visit/experience. Then, for each of the following statements, rate your level of agreement with how each statement reflects that most recent experience with the Health Care Provider/Physician.

  Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree N/A
Health Care Provider/Physician demonstrated knowledge of my medical history
Health Care Provider/Physician expressed understanding of my personal situation when considering my care decisions
Health Care Provider/Physician asked questions of me regarding my preferences
Health Care Provider/Physician listened to me carefully
Health Care Provider/Physician explained things in a way that was easy to understand

* 12. Again, please consider your most recent health care visit/experience. Then, for each of the following statements, rate your level of agreement with how each statement reflects that most recent experience with the Staff/Care Team.

  Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree N/A
Staff at the provider's office treated me with courtesy and respect
Staff explained things in a way that was easy to understand
Staff kept me informed of any delays to my scheduled appointment.
Staff followed up with me in a timely manner when I contacted the provider's office with questions and/or concerns
Staff are accessible during the standard lunch hour (12pm-1pm)
The care team (Physician, Nurse, Physician's Assistant) demonstrated that my health information was shared among members of the team

* 13. Please indicate how much you feel each of the following is a barrier to getting the health care that you need, or makes it more difficult.

  Major Barrier Minor Barrier Not a Barrier NA
Availability of information on area health care resources
Availability of information on cost of health care services
Coordination of resources among services and providers
Access to affordable health care
Access to holistic treatment options
Availability of transportation
Availability of child care
Ability to contact (no telephone)
Ability to take time off work for appointment/care

* 14. Where do you get health information?

  Yes Sometimes No
Doctor or health clinic
Family or friends
Health Department
Internet
Newspapers or magazines
Radio
Television

* 15. Please tell us about yourself. This anonymous personal health information helps us to plan programs and services where they are needed.

In which of the following counties do you live?

* 16. What is your age?

* 17. What is your highest level of education?

* 18. What is your annual household income?

* 19. Do you have health insurance?

* 20. What is your race/ethnicity?

* 21. Gender

* 22. Comments:

Thank you!

T