HealthEquityPatientSurvey20212022

Health Equity Improvement Plan

Colorado Primary Care Clinic is re-developing and re-designing its action plan to improve upon and better provide community resources for those in need. To best target our efforts to help meet your needs, please complete this survey in total. All of your data is confidential! Thank you for taking the time to complete this survey! Dr. Dawn

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* 1. Please provide your initials (First Name, Last Name) only

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* 2. Please list your birthday

Birthday

Date

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* 3. What is your age?

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* 4. What is your zip code?

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* 5. What race do you identify with the most?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Other (please specify)

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* 6. What ethnicity do you identify with the most?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another ethnicity

Other (please specify)

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* 7. Gender: How do you identify?

Female

Male

Transgender Female

Transgender Male

Prefer to self-describe, below

Self-describe:

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* 8. Do you think your race, ethnicity and /or gender identity create barriers to medical and mental healthcare?

Yes

If YES, (please describe)

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* 9. Chronic Disease...A Chronic disease would include but not be limited to the conditions in the table below. Please select all of the condition or conditions to the best of your knowledge that apply:

Alcohol Abuse or Misuse

Drug or Substance abuse or Misuse

Alzheimer's Disease or Related Dementia

Anxiety

Arthritis (Any type-osteoarthritis, rheumatoid, psoriatic)

Asthma (any type)

Atrial Fibrillation (Irregular Heart Beat)

Autism Spectrum Disorder (Any type)

Bipolar Disorder

Cancer (Any type-Active or in Remission)

Chronic Kidney Disease

COPD or Emphysema

Depression (Any type)

Diabetes (Any type, past or present)

Heart Failure

Hepatitis (Any type-acute or chronic)

HIV/AIDS

Hyperlipidemia (High Cholesterol)

Hypertension (High Blood Pressure)

Ischemic Heart Disease (Any Type-Coronary Arterosclerosis Disease, Acute Coronary Syndrome)

Obesity

Osteoporosis

Schizophrenia or other psychiatric disorder not listed above

Sleep Apnea (Any Type)

Stroke (Any type)

Other (please specify)

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* 10. Economic Stability- Financial Strain
How often does this describes you? I don’t have enough money to pay my bills?

Never

Rarely

Sometimes

Often

Always

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* 11. Can you pay all your bills in one month (Gas, electric, rent water, oil, gasoline, medical bills)?

Yes

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* 12. Employment: Do you want help finding or keeping work or a job?

Yes, help finding work

Yes, help keeping job

No, do not need or want help

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* 13. Neighborhood and Physical Environment
What is your zip Code

ZIP/Postal Code

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* 14. Housing instability: Do you have problems with any of the following?

Bug infestation

Mold

Lead paint or lead pipes

Inadequate heat

Oven or stove not working

No or not working smoking detectors

Water leaks

None of the above

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* 15. Transportation: Do you put off or neglect going to the doctor because of distance or transportation?

Yes

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* 16. Does your neighborhood provide safe parks and the ability to walk in the area safely?

Yes

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* 17. Do you feel safe at home?

Yes

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* 18. Education
Please indicate the following:

Highest level of school completed:

Primary Language Proficiency:

Secondary Language Proficiency:

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* 19. Food
Do you have access to healthy foods on a daily basis?

Yes

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* 20. Community Context and Social Context
Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

Yes

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* 21. Are you under stress?

Yes

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* 22. Are you suffering discrimination?

Yes

If YES, (please describe how)

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* 23. Health Care System
Do you think your health insurance creates barriers for your physical health care or mental health care?

Yes

If YES, (please describe)

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* 24. Health Insurance: Do you have health insurance with adequate provider availability, culturally sensitive providers and focus on quality of care?

Yes

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* 25. Mental Health and Substance Use Disorder
Mental Health
*Over the past 2 weeks, how often have you been bothered by any of the following problems?

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
a. Little interest or pleasure in doing things?	a. Little interest or pleasure in doing things? Not at all (0)	a. Little interest or pleasure in doing things? Several days (1)	a. Little interest or pleasure in doing things? More than half the days (2)	a. Little interest or pleasure in doing things? Nearly every day (3)
b. Feeling down, depressed, or hopeless?	b. Feeling down, depressed, or hopeless? Not at all (0)	b. Feeling down, depressed, or hopeless? Several days (1)	b. Feeling down, depressed, or hopeless? More than half the days (2)	b. Feeling down, depressed, or hopeless? Nearly every day (3)
c. Thoughts that you would be better off dead or of hurting yourself in some way	c. Thoughts that you would be better off dead or of hurting yourself in some way Not at all (0)	c. Thoughts that you would be better off dead or of hurting yourself in some way Several days (1)	c. Thoughts that you would be better off dead or of hurting yourself in some way More than half the days (2)	c. Thoughts that you would be better off dead or of hurting yourself in some way Nearly every day (3)

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* 26. Substance Use
The next set of questions relate to your experience with alcohol, cigarettes, and other drugs. Answer the questions if you use non-prescribed substances, or substances in higher quantities than prescribed by your provider. One question is about illicit or illegal drug use; we ask to best identify community services that may be available to help you.

	Never	Once or Twice	Monthly	Weekly	Daily or Almost Daily
a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Never	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Once or Twice	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Monthly	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Weekly	a. How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Daily or Almost Daily
b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)?	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Never	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Once or Twice	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Monthly	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Weekly	b. How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? Daily or Almost Daily
c. How many times in the past year have you used prescription drugs for non-medical reasons?	c. How many times in the past year have you used prescription drugs for non-medical reasons? Never	c. How many times in the past year have you used prescription drugs for non-medical reasons? Once or Twice	c. How many times in the past year have you used prescription drugs for non-medical reasons? Monthly	c. How many times in the past year have you used prescription drugs for non-medical reasons? Weekly	c. How many times in the past year have you used prescription drugs for non-medical reasons? Daily or Almost Daily
d. How many times in the past year have you used illegal drugs?	d. How many times in the past year have you used illegal drugs? Never	d. How many times in the past year have you used illegal drugs? Once or Twice	d. How many times in the past year have you used illegal drugs? Monthly	d. How many times in the past year have you used illegal drugs? Weekly	d. How many times in the past year have you used illegal drugs? Daily or Almost Daily

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* 27. List your priorities from 1 to 7 to identify the successful management of your health care and mental health using the following determinants:
1= Highest Need to 7= Lowest Need

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* 28. Are you using community resources to manage the priorities mentioned?

Yes

If yes, list the resources you use...
If no, explain the reason why you do not use community resources...

HealthEquityPatientSurvey20212022

Health Equity Improvement Plan

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* 1. Please provide your initials (First Name, Last Name) only

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* 2. Please list your birthday

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* 3. What is your age?

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* 4. What is your zip code?

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* 5. What race do you identify with the most?

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* 6. What ethnicity do you identify with the most?

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* 7. Gender: How do you identify?

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* 8. Do you think your race, ethnicity and /or gender identity create barriers to medical and mental healthcare?

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* 9. Chronic Disease...A Chronic disease would include but not be limited to the conditions in the table below. Please select all of the condition or conditions to the best of your knowledge that apply:

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* 10. Economic Stability- Financial StrainHow often does this describes you? I don’t have enough money to pay my bills?

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* 11. Can you pay all your bills in one month (Gas, electric, rent water, oil, gasoline, medical bills)?

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* 12. Employment: Do you want help finding or keeping work or a job?

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* 13. Neighborhood and Physical EnvironmentWhat is your zip Code

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* 14. Housing instability: Do you have problems with any of the following?

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* 15. Transportation: Do you put off or neglect going to the doctor because of distance or transportation?

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* 16. Does your neighborhood provide safe parks and the ability to walk in the area safely?

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* 17. Do you feel safe at home?

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* 18. EducationPlease indicate the following:

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* 19. FoodDo you have access to healthy foods on a daily basis?

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* 20. Community Context and Social Context Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

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* 21. Are you under stress?

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* 22. Are you suffering discrimination?

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* 23. Health Care SystemDo you think your health insurance creates barriers for your physical health care or mental health care?

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* 24. Health Insurance: Do you have health insurance with adequate provider availability, culturally sensitive providers and focus on quality of care?

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* 25. Mental Health and Substance Use Disorder Mental Health*Over the past 2 weeks, how often have you been bothered by any of the following problems?

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* 27. List your priorities from 1 to 7 to identify the successful management of your health care and mental health using the following determinants: 1= Highest Need to 7= Lowest Need

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* 28. Are you using community resources to manage the priorities mentioned?

* 10. Economic Stability- Financial Strain
How often does this describes you? I don’t have enough money to pay my bills?

* 13. Neighborhood and Physical Environment
What is your zip Code

* 18. Education
Please indicate the following:

* 19. Food
Do you have access to healthy foods on a daily basis?

* 20. Community Context and Social Context
Have you successfully identified with appropriated resources to help you with transition in the community where you live such as: faith organizations, family, friends, schools and community resources?

* 23. Health Care System
Do you think your health insurance creates barriers for your physical health care or mental health care?

* 25. Mental Health and Substance Use Disorder
Mental Health
*Over the past 2 weeks, how often have you been bothered by any of the following problems?

* 27. List your priorities from 1 to 7 to identify the successful management of your health care and mental health using the following determinants:
1= Highest Need to 7= Lowest Need