Mercy Medical Center is conducting a Community Health Needs Assessment (CHNA) survey to better understand the health concerns and needs in the community. The information obtained from the CHNA will be used in the development of an action plan to help improve the health of local community members. Thank you in advance for completing this survey.

Question Title

* 1. How would you describe your overall health?

Question Title

* 2. Please select the top three health challenges you face.

Question Title

* 3. Where do you go for routine health care?

Question Title

* 4. Are there any issues that prevent you from accessing care? (Check all that apply.)

Question Title

* 5. What is needed to improve the health of your family and neighbors? (Check three.)

Question Title

* 6. What types of health screenings and/or services are needed to keep you and your family healthy? (Check up to five.)

Question Title

* 7. What health issues do you need education about? (Please check up to five.)

Question Title

* 8. Where do you get most of your health information? (Check all that apply.)

Question Title

* 9. What additional health services need to be offered to meet health challenges in your community?

Question Title

* 10. Please choose all statements below that apply to you.

Question Title

* 11. Which of the folliowing preventive procedures have you had in the past 12 months?

Question Title

* 12. How can Mercy Medical Center better meet your health care needs?

Question Title

* 13. Optional: What is your gender?

Question Title

* 14. Optional: In what zip code is your home located? (Enter five digit zip code; for example, 11570 or 11550.)

Question Title

* 15. Optional: Which category below includes your age?

Question Title

* 16. Optional: What is your highest level of education?

Question Title

* 17. Optional: What is your race?

Question Title

* 18. Optional: Do you have health insurance?

Question Title

* 19. Optional: Would you like to receive additional information about free or low-cost health programs at Mercy Medical Center in Rockville Centre?

T