1. What is your ethnic origin? (Check one) 2. What is your gender? 3. What is your age? Page 1. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj. nmlkj.
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1 1. What is your ethnic origin? (Check one) White Asian/Pacfic Island American Indian Black Hispanic 2. What is your gender? Female Male 3. What is your age? 18 to to to to to or older 45 to 54 Page 1
2 4. In what zip code do you currently reside? What is your approximate average household income? $0 $24,999 $75,000 $99,999 $150,000 $174,999 $25,000 $49,999 $100,000 $124,999 $175,000 $199,999 $50,000 $74,999 $125,000 $149,999 $200,000 and up 6. What is the highlest level of education you have completed? (Check one) Some High School no diploma Bachelors Degree High School or GED Masters Degree Technical School or Trade School Certificate Postgraduate Degree or Professional Degree (PhD, MD, JD) Associate Degree 7. Do you currently have health insurance? Page 2
3 8. If you answered yes to health insurance, what type do you have? (Check all that apply) Employer Based Program Health Insurance Market Place/Federal Exchange Policy Medicare Indian Health Medicaid VA Commercial/Individual Policy 9. In general, how would you rate your overall health? Excellent Very good Good Fair Poor 10. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor Page 3
4 11. Have you been told you have any of the following health conditions? (Check all that apply) Arthritis Heart Attack Overweight more than 30 lbs. Asthma Heart Failure Thyroid Disorder Cancer High Cholesterol Sleep Disorder Chronic Back Pain Hypertension Stroke Chronic Lung Disease Migraines Kidney/Renal Disease Depression/Anxiety Osteoporosis Diabetes Overweight less than 30 lbs. Page 4
5 12. How many days in the past month were you not able to work due to poor physical health? ne 1 5 days 5 10 days days days 13. How many days in the past month have you experienced emotional problems that affected your ability to perform you daily responsibilities? ne 1 5 days 5 10 days days 14. Do you have a primary healthcare provider? (Physician, Nurse Practitioner) 15. In the last 12 months, how many times did you visit your healthcare provider? ne 4 times 1 time 5 to 9 times 2 times 10 or more times 3 times Page 5
6 16. When was your last routine check up? In the last year 2 years More than 2 years t Sure 17. Was there a time in the past 12 months that you needed to see a doctor but could not? 18. If yes, please check all that apply. Appointment time was longer than 6 weeks Cost Could not get a referral to see a specialist Provider was out of my insurance network Transportation Office hours were not convenient 19. In the past month, have you used any of the following services? (Check all that apply) Urgent Care Chiropractor Diagnostic Imaging (X Ray, MRI, Walk In Pharmacy Clinic Physician/Nurse Practitioner Clinic Acupuncturist Physical Therapy Ultrasound) Hospital Admission Emergency Room Lab (blood work) Page 6
7 20. Do you utilize any of the following screenings as part of your regular routine checkup? Check all that apply. Dental Vision Flu Vaccine Comment 21. Have you had any of the cancer screenings listed below? (Check all that apply) Mammogram & Breast Exam Fecal Occult Blood Test Prostate Specific Antigen (PSA) Sigmoidoscopy/Colonoscopy Digital Rectal Exam Skin Cancer Screening Cervical Exam & Pap Smear 22. If you have been told that you have high blood cholesterol are you taking medication and/or making lifestyle changes to control it?, taking medication, making lifestyle changes, doing both changes made This question does not apply to me 23. If you have been told your blood pressure is too high, are you taking medication and/or making lifestyle changes?, taking medication, making lifestyle changes, doing both changes made This question does not apply to me Page 7
8 24. If you have been told that your blood sugar or A1C is too high, are you taking medication and/or making lifestyle changes to control it?, taking medication, making lifestyle changes, doing both changes made This question does not apply to me Page 8
9 25. In a typical week, how many days do you exercise? I don't regularly exercise Once a week 2 to 4 days a week 5 to 7 days a week 26. In a typical week, how many times do you eat at fast food restaurants? ne 1 2 times 3 4 times 5 or more times 27. Do you currently smoke cigarettes, or not?, I do, I do not 28. Do you currently use smokeless tobacco? Page 9
10 29. How many times have you tried to quit using tobacco products? 1 5 times 5 10 times 10 or more times 30. When you tried to quit using tobacco, did you use any of the products and/or tactics below? (Check all that apply) NRT (Nicotine Repalcement Therapy) patches, lozenges, gum, Counseling Prescription Medicine (Chantix,Zyban,etc.) Classes E Cigarettes Cold Turkey Vapors 31. When you imagine a strong, vibrant community what are the features you think of? (Please choose 3) Senior Housing Good Schools Safe Environment Clean Environment Economic Opportunities Good Childcare Transportation Diverse Populations Mental Health Services Affordable Housing Drug & Alcohol Free Communities Walkable and Bike Friendly Communities Livable Wages Healthy Food Choices Health Care Services Senior Services Parks and Recreation Resources Arts & Entertainment 32. In the past year, have you given your time without pay to any charitable, civic, religious or other volunteer organization? Page 10
11 33. In the past year, have you donated money to any charitable, civic, religious or other volunteer organization? Page 11
12 34. When seeking healthcare, does it matter if a hospital is not for profit or for profit? A notfor profit hospital means the facility does not pay either state or local property taxes or federal income taxes because it is considered a charity, and provides certain community benefits in accord with state and federal guidelines. A for profit, or investor owned, hospital means the facility is either owned by private investors or is owned publicly by shareholders and is part of a company that issues shares of stock to raise revenue to expand the hospital activities. t Sure Comment 35. rman Regional Hospital Authority is a not for profit health system and a public trust of the City of rman, created for charitable purposes. Does this status matter to you when seeking health care services? t Sure Comment Page 12
13 36. How do you prefer to receive health information? Please rank in order of preference. 6 Internet 6 Healthcare related websites 6 Social Media (Facebook, Twitter) 6 E Mail 6 Newspaper 6 Newsletter 6 Radio 6 Television Page 13
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