WeaverMountain Health Initiative/Community Health Needs Assessment

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Image Field
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OPTIONAL INFORMATION BUT GREATLY APPRECIATED
First Name
Last Name
Phone number
Email ID
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YOUR HOUSEHOLD PROFILE
Street Address
City
State
ZIP code
Number in Household
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Approximate Age Information & Number of Each In Household
Under 5
6-17
18-24
25-44
45-64
65-75
Over 75
Male
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Female
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Male
Female
Under 5
Row 0, Column 0
6-17
Row 0, Column 1
18-24
Row 0, Column 2
25-44
Row 0, Column 3
45-64
Row 0, Column 4
65-75
Row 0, Column 5
Over 75
Row 0, Column 6
Under 5
Row 1, Column 0
6-17
Row 1, Column 1
18-24
Row 1, Column 2
25-44
Row 1, Column 3
45-64
Row 1, Column 4
65-75
Row 1, Column 5
Over 75
Row 1, Column 6
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What healthcare services do you regularly use?
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What is (are) the specialty area(s) you use? Primary Care, OB/GYN, Cardiac, Allergy, Diabetes, Kidney, Wound Care, etc.
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Where do you normally get your prescription?Name & Location
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How frequently to you seek healthcare services?Use Drop Down Menu
Weekly
Monthly
Bi-Annually
Annually
Other
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How many miles do you travel for healthcare services?
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Which town or city describes the place where you most often go when you need medical care?Use Drop Down Menu
Congress
Phoenix area
Prescott
Wickenburg
Other
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What is the name of the businesses you visit for healthcare services? Please identify the name of the practice(s) and location
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If you are employed, what town or city do you work in?
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Is transportation an issue for you to access healthcare services?
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What is the likelihood of using a more convenient location for your healthcare needs?Use Drop Down Menu
Very Likely
Perhaps
Not Sure
No
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Where do you suggest that location be in your area?
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To supplement going to your regular Doctor, would you like having access to telemedicine using your phone or computer for routine needs such as needing a non-narcotic prescription like a Z-Pack or to ask a general medical question?
Yes
No
Maybe
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During the past 30 days how often have you felt isolated from others?Use Drop Down Menu
Every day
Most of the time
Some of the time
Hardly ever
Never
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Which of the following best describes the place where you most often go when you need medical care?Use Drop Down Menu
Clinic or health center
Doctor’s office
Clinic in a store or pharmacy
Hospital emergency room
Hospital outpatient department
Urgent Care
I don’t go to one place most often
Some other place
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If you wanted to buy fresh fruits and vegetables, how easy would it be for you to do so?Use Drop Down Menu
Very easy
Somewhat easy
Somewhat difficult
Very difficult
I don’t purchase fresh fruits and vegetables
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Please indicate how safe you feel in the following placesUse Drop Down Menu
Please Select
Please Select
Very Safe
Somewhat Safe
Somewhat Unsafe
Unsafe
In your home during the day
Please Select
Please Select
Very Safe
Somewhat Safe
Somewhat Unsafe
Unsafe
In your home at night
Please Select
Please Select
Very Safe
Somewhat Safe
Somewhat Unsafe
Unsafe
Walking in your community during the day
Please Select
Please Select
Very Safe
Somewhat Safe
Somewhat Unsafe
Unsafe
Walking in your community at night
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Please indicate the degree to which you feel each of the following statements describes youUse Drop Down Menu
Please Select
Please Select
Very much like me
Somewhat like me
Not like me
If I need support, I know who I can call on
Please Select
Please Select
Very much like me
Somewhat like me
Not like me
I have people I feel close to
Please Select
Please Select
Very much like me
Somewhat like me
Not like me
I feel part of a group of friends
Please Select
Please Select
Very much like me
Somewhat like me
Not like me
I know there are people who really understand me
Please Select
Please Select
Very Much Like Me
Somewhat Safe
Somewhat Unsafe
Unsafe
I feel connected to my family and relatives
Please Select
Please Select
Very much like me
Somewhat like me
Not like me
I have a lot in common with the people I know
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What kind of health insurance or health care coverage do you have?Use Drop Down Menu
Private Health Insurance
Medicaid
Medicare
Military Health care (VA)
Indian Health Service
No Coverage
Do Not Know
Other
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Would you like to be added to an email list and phone list to keep you informed of healthcare and other initiatives? Please make sure you gave us your Email ID at the beginning of the survey
YESNO
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Enter your Email* This field is required.
example@example.com
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Please add any comments you would like to add that would help improve access to healthcare for you.
Huge
Large
Normal
Small
Ok
Ok
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I certify that only one on-line survey on this subject has been completed for our household.
Should be Empty: