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Community Health Needs Assessment 2016
Please be honest with your answers. Participants will not be held accountable by law for any answers on this survey. (For instance, if you answer that you use illegal drugs, we will not contact law enforcement.)
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1.
How would you describe your overall health?
(Required.)
Excellent
Very Good
Fair
Poor
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2.
Please select the top three health challenges you face.
(Required.)
Alcohol overuse
Cancer
Diabetes
Drug addiction
Heart disease
High blood pressure
Joint pain or back pain
Lung disease
Mental health issues
Overweight/obesity
Stroke
I do not have any health challenges
Other (please specify)
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3.
Where do you go for routine health care?
(Required.)
Physician's office
Public health department
Emergency room
Urgent care clinic
Other clinic
I do not receive routine health care
I would not seek health care
Other (please specify)
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4.
Where would you go for emergency medical services if you were able to take yourself?
(Required.)
Emergency room
Urgent care clinic
Physician's office
Public health
Other clinic
I would not seek health care
Other (please specify)
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5.
Are there any issues that prevent you from accessing care?
(Required.)
Cultural/religious beliefs
Don't know how to find doctors
Don't understand the need to see a doctor
Fear (e.g., not ready to face/discuss health problem)
Lack of availability of doctors
Language barriers
No insurance and/or unable to pay for the care
No barriers
Unable to pay co-pays/deductibles
Transportation
Other (please specify)
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6.
What is needed to improve the health of your family and neighbors?
(Required.)
Free or affordable health screenings
Health insurance coverage
Healthier food
Job opportunities
Mental health services
Recreation facilities
Safe places to walk/play
Specialty physicians
Substance abuse rehabilitation services
Transportation
Wellness services
I don't know
Other (please specify)
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7.
What types of health screenings and/or services are needed to keep you and your family healthy? (Check up to five)
(Required.)
Blood pressure
Cancer
Cholesterol (fats in the blood)
Dental screenings
Diabetes
Disease outbreak prevention
Drug and alcohol abuse
Eating disorders
Emergency preparedness
Exercise/physical activity
Falls prevention for the elderly
Heart disease
HIV/AIDS and STDs
Memory loss
Mental health/depression
Nutrition
Prenatal care
Quitting smoking
Routine well checkups
Suicide prevention
Vaccination/immunizations
Weight-loss help
Other (please specify)
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8.
What health issues do you need education about? (Please check up to five)
(Required.)
Blood pressure
Cancer
Cholesterol
Dental screenings
Diabetes
Disease outbreak prevention
Drug and alcohol abuse
Eating disorders
Emergency preparedness
Exercise/physical therapy
Falls prevention in the elderly
Heart disease
HIV/AIDS and STDs
Mental health/depression
Nutrition
Prenatal care
Quit smoking
Routine well checkups
Suicide prevention
Vaccination/immunizations
Other (please specify)