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1. How would you describe your overall health?
2. Please select the top three health challenges you face.
CancerDiabetesOverweight/obesityLung diseaseHigh blood pressureStrokeHeart DiseaseJoint pain or back painMental health issuesAlcohol overuseDrug addictionI do not have any health challengesOther
3. Where do you go for routine health care?
Physician’s officeHealth departmentEmergency roomUrgent care clinicOther clinicI do not receive routine health careI would not seek health care
4. Where would you go for emergency medical services if you were able to take yourself?
5. Are there any issues that prevent you from accessing care? (check all that apply)
Cultural/religious beliefsDon’t know how to find doctorsDon’t understand the need to see a doctorFear (e.g., not ready to face/discuss health problem)Lack of availability of doctorsLanguage barriersNo insurance and unable to pay for the careUnable to pay co-pays/deductiblesTransportationOther
6. What is needed to improve the health of your family and neighbors? (Check three)
Healthier foodMental health servicesTransportationSpecialty physiciansSafe places to walk/playJob opportunitiesRecreation facilitiesWellness servicesFree or affordable health screeningsSubstance abuse rehabilitation servicesOther
7. What types of health screenings and/or services are needed to keep you and your family healthy? (Check up to five)
Blood pressureCancerCholesterol (fats in blood)Dental screeningsDiabetesDisease outbreak preventionDrug and alcohol abuseMental health/depressionEmergency preparednessExercise/physical activityFalls prevention for elderlyHeart diseaseHIV/AIDS & STDsRoutine well checkupsMemory lossNutritionPrenatal careQuit smokingSuicide preventionVaccinationsWeight-loss helpEating DisordersOthers
8. What health issues do you need education about? (Please check up to five)
9. Where do you get most of your health information? (Check all that apply)
Doctor/healthcare providerHospitalChurch groupFacebook or TwitterInternetSchool or collegeOther social mediaLibraryTVFamily or friendsNewspaper/magazineWorksiteHealth departmentRadioOther
10. What additional health services need to be offered to meet health challenges in your community?
11. Please choose all statements below that apply to you.
I exercise at least three times per week.I eat at least five servings of fruits and vegetables each day.I eat fast food more than once per week.I smoke cigarettes.I chew tobacco.I use illegal drugs.I abuse or overuse prescription drugs.I have more than four alcoholic drinks (if female) or five (if male) per day.I use sunscreen or protective clothing for planned time in the sun.I receive a flu shot each year.I have access to a wellness program through my employer.None of the above apply to me
12. Which of the following preventive procedures have you had in the past 12 months?
Mammogram (woman)Pap smear (woman)Flu shotProstate screening (man)Cholesterol screeningVision screeningHearing screeningCardiovascular screeningColon/rectal examBone density testBlood pressure checkDental cleaning/x-raysBlood sugar checkSkin cancer screeningPhysical examNone of the above
13. How can Glenn Medical Center better meet your health care needs?
14. Optional: What is your gender?
15. Optional: Which category below includes your age?
16. Optional: What is your highest level of education?
K-8 gradeSome high schoolHigh school graduateTechnical schoolSome collegeCollege graduateGraduate schoolDoctorateOther
17. Optional: Do you have health insurance?
YesNoNo, but I did previously
18. Optional: Do you need a Primary Care Physician? (Family Practice/Internal Medicine). If so, please provide your contact information at the end of the survey
19. Are you in need of a health specialist? Please check all that apply and include your contact information at the end of the survey
CardiologyObstetricsThoracic surgeryElectrophysiologyBariatric/Weight lossVascular surgeryOrthopedicsGeneral surgeryOncologyNeurologyGastroenterologyPlastic SurgeryNeurosurgeryUrologyPain managementColorectalOncologyWound healingGynecologyBreast HealthSleep DisordersOther
Please list any areas in which our service could be improved.
Please share any additional comments.
Personal InformationProviding the following information is optional.
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Thank you for taking the time to fill out our survey.