COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY SFH St. Francis Hospital - The Heart Center is conducting a Community Health Needs Assessment Survey. By answering these questions, you will help us identify the most important health needs in your community so that we can develop goals to meet them. Question Title * 1. What are the biggest health issues or concerns in your community? (Check all that apply) Asthma/lung disease Cancer Diabetes HIV/AIDS Heart disease Mental Health/depression/suicide Stroke I don’t know Other (please specify) Question Title * 2. What keeps people in your community from seeking medical treatment? (Check all that apply) Lack of insurance Unable to pay co-pays Health services too far away Cultural or religious beliefs Fear (not ready to face health problem) Don’t understand the need to see doctor Transportation problems Child Care problems No appointments available Too long of a wait at the doctor’s office Too long of a wait to get an appointment to see doctor No access to primary care physicians/doctors Language barrier/do not speak my language Don’t know how to find doctors None/no barriers I don’t know Other (please specify) Question Title * 3. What is needed to improve the health of your family and neighbors? (Check all that apply) Healthier food Job opportunities Mental health services Recreation facilities Transportation Wellness services Specialty physicians Safe places to walk/play Substance abuse rehabilitation services I don’t know Other (please specify) Question Title * 4. What health screenings or education/information services are needed in your community? (Check all that apply) Cancer Cholesterol Blood pressure Heart disease Diabetes Dental screenings Disease outbreaks Substance abuse Nutrition Exercise/physical activity Emergency preparedness Eating disorders Falls prevention HIV/sexually transmitted diseases Mental health Vaccination/immunizations Prenatal care Other (please specify) Question Title * 5. If you or someone in your family were ill and required medical care, where would you go? (Check one) Doctor’s office Clinic Hospital emergency department Walk-in/urgent care center Health department Would not seek care Other (please specify) Question Title * 6. Where do you and your family get most of your health information? (Check all that apply) Family or friends Newspaper/Magazines Library Internet Doctor/health professional Television Hospital Health department Radio Religious organization School Other (please specify) Question Title * 7. When seeking care, which hospital would you visit first? (Check one) St. Francis Hospital North Shore–LIJ Winthrop University Hospital Stony Brook U. Medical Center Brookhaven Memorial Hospital St. Charles Hospital John T. Mather Memorial Hospital Nassau University Medical Center New York Presbyterian Hospital (Columbia/Weill Cornell) New York Hospital Queens Good Samaritan Medical Center South Nassau Communities Hospital Mercy Medical Center St. Catherine of Siena St. Joseph Hospital Other (please specify) Question Title * 8. Have you had a routine physical exam in the past two years? Yes No Question Title * 9. What is your gender? Female Male Question Title * 10. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 11363 or 94305) Question Title * 11. Which category below includes your age? Under 18 18-29 30-39 40-49 50-59 60-69 70-79 80-89 90+ Question Title * 12. What is your racial/ethnic identification? White/Caucasian Black/African American Native American Asian Hispanic Multi-racial Other (please specify) Question Title * 13. What is your highest level of education? K-8 grade Some high school High school graduate Technical school Some college College graduate Graduate school Doctorate Other (please specify) Question Title * 14. Do you have health insurance? Yes No No, but I did at an earlier time/previous job Done