We need your voice!

We are wanting your opinion so that Weisbrod Memorial County Hospital can better serve your community.  We appreciate you taking the time to complete this survey that is estimated to take 10 minutes.  All responses are anonymous and evaluated by a third-party entity.  If you have any questions, please direct them to Megan Little at mlittle@verticalstrategies.net.

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* 1. Please list your zip code

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* 2. How much of each year do you spend in this residence?

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* 3. What is your age

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* 4. What was your household income range last year?

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* 5. What is your gender?

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* 6. What race do you identify most closely?

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

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* 8. Which of the following categories best describes your employment status?

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* 9. What is the highest level of school you have completed or the highest degree you have received?

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* 10. In the following list, what do you think are the three most important factors for a healthy community? (Those factors which most improve the quality of life in a community.)

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* 11. In the following list, what do you think are the three most important “health problems” in our community? (Those problems which have the greatest impact on overall community health.)

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* 12. How would you rate the overall health of our community?

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* 13. How would rate your own personal health?

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* 14. Are you satisfied with the quality of life in our community? (Consider your sense of safety, wellbeing, participation in community life and associations, etc.)

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* 15. Are you satisfied with the healthcare system in the community? (Consider access, cost, availability, quality, and options in healthcare)

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* 16. This community is a good place to raise children (Consider school quality, day care, after school programs, recreation, etc.)

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* 17. This community is a good place to grow old? (Consider elder-friendly housing, transportation to medical services, churches, shopping; elder day care, social support for the elderly living alone, meals on wheels, etc.)

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* 18. There is economic opportunity in the community? (Consider locally owned and operated businesses, jobs with career growth, job training/higher education opportunities, affordable housing, reasonable commute, etc.)

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* 19. The community is a safe place to live? (Consider residents’ perceptions of safety in the home, the workplace, schools, playgrounds, parks, and the mall. Do neighbors know and trust one another? Do they look out for one another?)

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* 20. There are networks of support for individuals and families (neighbors, support groups, faith community outreach, agencies, organizations) during times of stress and need?

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* 21. All individuals and groups have the opportunity to contribute to and participate in the community’s quality of life?

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* 22. All residents perceive that they — individually and collectively — can make the community a better place to live?

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* 23. There are a broad variety of health services in the community?

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* 24. There is a sufficient number of health and social services in the community?

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* 25. The levels of mutual trust and respect increasing among community partners as they participate in collaborative activities to achieve shared community goals?

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* 26. There is an active sense of civic responsibility and engagement, and of civic pride in shared accomplishments?

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* 27. Have you or someone in your household used the services of a hospital in the past 24 months?

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* 28. If you responded that you or someone in your household received care at a hospital other than Weisbrod Memorial County Hospital, why did you or your family member choose that/those hospital(s)?

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* 29. When you or a family member have visited Weisbrod Memorial County Hospital, how satisfied were you with the services you received?

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* 30. What type(s) of specialist(s) have you or someone in your household been to within the past 24 months?

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* 31. What types of health centers have you or a family member visited within the past 24 months?

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* 32. Please tell us all the cities you and/or family members in your household received care in the last 24 months.

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* 33. If you or a family member have seen a healthcare provider outside the Eads area because of choice only, what were your reasons?

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* 34. What type(s) of health insurance do you and your family have?

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* 35. What do you think Weisbrod Memorial County Hospital does best?

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* 36. What do you think Weisbrod Memorial County Hospital should start doing?

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* 37. How many days in the last month were you not able to fully complete your activities because of poor physical and/or mental health?

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* 38. How many days within the past month was your mental health poor? This includes high levels of stress, depression and other emotional problems.

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* 39. Within the past year, have you needed any of the following mental health services?

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* 40. Out of the services you answered "yes" to above, were there barriers to getting the care you needed? If so, please explain.

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* 41. During the past 30 days, how many days did pain make it hard for you to do your usual activity like self care, work, and recreation?

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* 42. During the past week, other than your regular job, did you participate in any moderate activities for at least 30 minutes each time? (Include brisk walking or anything else that causes increased breathing and heart rate)

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* 43. Which of the following best describes your smoking/tobacco use status?

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* 44. When was the last time you:

  Never Within the past year 1-2 years ago 3-5 years ago More than 5 years ago N/A
Visited a dentist or dental clinic for any reason?
Had your teeth cleaned by a dentist or hygienist
Had a flu shot
Had a colorectal screening
Had your blood pressure checked
Had a skin cancer check
Had a blood sugar test
Had a routine check up
Had a mammogram (female only)
Had a breast exam other than a mammogram
Had a PAP test (female only)
Had a prostate exam (male only)
Had a digital rectal exam (male only)

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* 45. Was there a time within the past 12 months when you couldn't see a doctor or provider: (please indicate all that apply)

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* 46. During the past 12 months, was there a time you did not get your prescription medications because of cost?

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* 47. If you do not have health insurance, what are the reasons? (select all that apply)

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* 48. Do you or anyone in your household prefer to speak a language other than English at home?

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* 49. Where do you get your health information? (check all that apply)

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* 50. What else would you like Weisbrod Memorial County Hospital to know?

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* 51. Please provide your contact information if you'd like to talk with Weisbrod Memorial County Hospital about the survey.

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