Community Health Needs Survey 2015

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33% of survey complete.

The survey will take only about 15 minutes. Your responses are confidential and will be combined with the responses of others. You will not be identified by name, and no one will see your individual responses.

Thank you for participating in our survey – your responses will help us to improve the programs and services that we offer.

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* 1. These last questions will help us combine your answers with those of others.
In what ZIP code is your home located?

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* 2. What do you feel are the 3 most important social problems in your community? (Please check three boxes)

Affordable Housing

Poor Health of Residents

Hunger

Lack of Education / Job Training

Lack of Employment Opportunities

Pollution (Clean, safe air quality)

Poverty

Public Safety

Public Transportation

Violence

Other (please specify)

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* 3. And what do you feel are the 3 most important health problems in your community? (Please check three boxes)

Asthma

Breathing Problems

Cancer

Dental/Oral Health

Diabetes

Heart Disease

Hearing/Vision Problems

HIV/AIDS

Infant Mortality

Injuries

Mental Health (depression, anxiety, sadness)

Obesity

Smoking and Tobacco Use

Stroke

Substance Abuse (alcohol, drugs)

Other (please specify)

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* 4. What do you feel are the top 3 reasons why obesity is an issue in your community? (Check three boxes)

Obesity is not a problem in my community (Skip to question 4)

Healthy habits not promoted/supported in the community, schools and churches

Lack of access to healthy and affordable foods (fruits and vegetables)

Lack of access to parks and places to exercise

Lack of access to low-cost weight loss programs

Lack of knowledge about nutrition

Lack of recreation/ physical activity programs

Lack of support from employers

Lack of support from hospitals and medical professionals

Safety reasons (personal/traffic/neighborhood)

Unhealthy diet and exercise habits

Other (please specify)

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* 5. Which of the following make it harder for you and your household members to get health care services? (Check all that apply)

Don’t have trouble getting health care services (Skip to question 5)

Can’t find programs/services that meets my needs

Cost of co-pays

Don’t know what is available in my community

Lack of affordable transportation

Lack of doctors/providers who accept my insurance

Lack of insurance

Language barrier

Limited hours at doctor’s office/clinic

Not able to get timely appointment to see doctor/provider

Public transportation that is not available or too limited

Unable to find a primary care doctor

Unable to find a specialist

Other (please specify)

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* 6. Which of the following make it harder for you and your household members to get mental health services, such as counseling for loss, divorce, stress, depression, substance abuse or other issue? (Check all that apply)

Don’t need mental health services (Skip to question 6)

Don’t have problem getting services

Can’t find program/services that meets my needs

Concern about what other people think

Cost of co-pay

Don’t know what is available in my community

Lack of insurance

Lack of affordable transportation

Lack of doctors/providers who accept my insurance

Limited hours at doctor’s office/clinic

Not able to get timely appointment to see doctor/provider

Unable to find a doctor/provider

Other (please specify)

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* 7. How would you rate health care services available to you in Northwest Indiana? (Check one box)

Excellent

Very Good

Good

Fair

Poor

Don't Know/Not Sure

Excellent

Very Good

Good

Fair

Poor

Don't Know/Not Sure

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* 8. How would you describe your overall health? (Check one box)

Excellent

Very Good

Good

Fair

Poor

Don't Know/Not Sure

Excellent

Very Good

Good

Fair

Poor

Don't Know/Not Sure

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* 9. Was there a time within the past year that you did not purchase or took less of a prescription medication because you could not afford it?

Yes

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* 10. Do you have a primary care doctor?

Yes (Skip to question 12)

No (Continue to question 11)

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* 11. If no, what is the main reason you do not have a primary care doctor? (Check only one box)

Don’t need one at this time

Can’t find a doctor who takes my insurance

Can’t get appointment

Don’t have Insurance

Don’t trust doctors

Not enough doctors in my community

Prefer to see specialists for all health needs

Too costly

Other (please specify)

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* 12. When you need healthcare, where do you usually go for services? (Please check one box)

Clinic or urgent/Immediate care facility

Free or Low Cost Clinic (such as a Federally Qualified Health Care Clinic )

Hospital Emergency Department

A doctor’s office

Veteran’s Administration Healthcare

Other (please specify)

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* 13. For each type of care below, please tell us where you and members of your household primarily go to receive it by checking the box that best applies to you.

	Primarily in NWI	Primarily Outside of NWI	Need Service but Don’t Get it	Don’t need Service
Cancer Care	Cancer Care Primarily in NWI	Cancer Care Primarily Outside of NWI	Cancer Care Need Service but Don’t Get it	Cancer Care Don’t need Service
Chronic Disease Treatment (heart disease, stroke, diabetes)	Chronic Disease Treatment (heart disease, stroke, diabetes) Primarily in NWI	Chronic Disease Treatment (heart disease, stroke, diabetes) Primarily Outside of NWI	Chronic Disease Treatment (heart disease, stroke, diabetes) Need Service but Don’t Get it	Chronic Disease Treatment (heart disease, stroke, diabetes) Don’t need Service
Dental/oral healthcare	Dental/oral healthcare Primarily in NWI	Dental/oral healthcare Primarily Outside of NWI	Dental/oral healthcare Need Service but Don’t Get it	Dental/oral healthcare Don’t need Service
Eye/vision care	Eye/vision care Primarily in NWI	Eye/vision care Primarily Outside of NWI	Eye/vision care Need Service but Don’t Get it	Eye/vision care Don’t need Service
Specialist care(such as cardiologist, neurologist)	Specialist care(such as cardiologist, neurologist) Primarily in NWI	Specialist care(such as cardiologist, neurologist) Primarily Outside of NWI	Specialist care(such as cardiologist, neurologist) Need Service but Don’t Get it	Specialist care(such as cardiologist, neurologist) Don’t need Service
Mental health care (such as counseling, substance abuse treatment, testing, diagnosis)	Mental health care (such as counseling, substance abuse treatment, testing, diagnosis) Primarily in NWI	Mental health care (such as counseling, substance abuse treatment, testing, diagnosis) Primarily Outside of NWI	Mental health care (such as counseling, substance abuse treatment, testing, diagnosis) Need Service but Don’t Get it	Mental health care (such as counseling, substance abuse treatment, testing, diagnosis) Don’t need Service
Prenatal care	Prenatal care Primarily in NWI	Prenatal care Primarily Outside of NWI	Prenatal care Need Service but Don’t Get it	Prenatal care Don’t need Service
Primary care (such as family doctor, nurse practitioner)	Primary care (such as family doctor, nurse practitioner) Primarily in NWI	Primary care (such as family doctor, nurse practitioner) Primarily Outside of NWI	Primary care (such as family doctor, nurse practitioner) Need Service but Don’t Get it	Primary care (such as family doctor, nurse practitioner) Don’t need Service
Surgery	Surgery Primarily in NWI	Surgery Primarily Outside of NWI	Surgery Need Service but Don’t Get it	Surgery Don’t need Service

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* 14. In column A below, please tell us whether you or someone in your household has been diagnosed with any of the conditions listed. (Check all that apply)
In Column B, please check the box beside each condition that has limited or caused major impairment to your lifestyle. (Check all that apply)

	(A) - You or Someone in your household has been Diagnosed	(B) - This condition limits or has caused major impairment to your lifestyle
Cancer	Cancer (A) - You or Someone in your household has been Diagnosed	Cancer (B) - This condition limits or has caused major impairment to your lifestyle
Depression /Mental Health Issues	Depression /Mental Health Issues (A) - You or Someone in your household has been Diagnosed	Depression /Mental Health Issues (B) - This condition limits or has caused major impairment to your lifestyle
Diabetes	Diabetes (A) - You or Someone in your household has been Diagnosed	Diabetes (B) - This condition limits or has caused major impairment to your lifestyle
Heart Condition	Heart Condition (A) - You or Someone in your household has been Diagnosed	Heart Condition (B) - This condition limits or has caused major impairment to your lifestyle
Lung Disease, such as bronchitis or emphysema	Lung Disease, such as bronchitis or emphysema (A) - You or Someone in your household has been Diagnosed	Lung Disease, such as bronchitis or emphysema (B) - This condition limits or has caused major impairment to your lifestyle
Obesity	Obesity (A) - You or Someone in your household has been Diagnosed	Obesity (B) - This condition limits or has caused major impairment to your lifestyle

If you or someone in your household has any other conditions that have limited or caused major lifestyle impairment, please write in below.

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* 15. In the past 12 months have you or anyone in your household visited the Emergency Room (ER) for any of the following? (Check all that apply)

Did not visit the ER in the past 12 months (Skip to Question 15)

Breathing problems (asthma, COPD)

Blood sugar (diabetes)

Broken bones

Cancer

Common illness (colds, ear infections, fever, rash, flu)

Dental/oral health

Depression/Anxiety/Mental Health Issues

Heart Condition

Injury

Pain Relief

Stroke

Substance Abuse (Alcohol, Drugs)

Just needed access to a physician

Other (please specify)

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* 16. Have you or member of your household been the victim of physical violence in the past five years (domestic/street/gang/criminal violence?)

Yes

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* 17. Do you undergo the following preventive procedures on a regular basis? (Check the appropriate box for each item)

	Yes	No	N/A
Breast Exam/Mammogram	Breast Exam/Mammogram Yes	Breast Exam/Mammogram No	Breast Exam/Mammogram N/A
Blood Pressure Screening	Blood Pressure Screening Yes	Blood Pressure Screening No	Blood Pressure Screening N/A
Cholesterol Screening	Cholesterol Screening Yes	Cholesterol Screening No	Cholesterol Screening N/A
Colon Exam	Colon Exam Yes	Colon Exam No	Colon Exam N/A
Diabetes Screening	Diabetes Screening Yes	Diabetes Screening No	Diabetes Screening N/A
Flu Shot	Flu Shot Yes	Flu Shot No	Flu Shot N/A
Immunization Screening	Immunization Screening Yes	Immunization Screening No	Immunization Screening N/A
Lung Screening	Lung Screening Yes	Lung Screening No	Lung Screening N/A
Pap Smear	Pap Smear Yes	Pap Smear No	Pap Smear N/A
Pneumonia shot	Pneumonia shot Yes	Pneumonia shot No	Pneumonia shot N/A
Skin Cancer screening	Skin Cancer screening Yes	Skin Cancer screening No	Skin Cancer screening N/A
Prostate Screening	Prostate Screening Yes	Prostate Screening No	Prostate Screening N/A
Well Exam for my child	Well Exam for my child Yes	Well Exam for my child No	Well Exam for my child N/A

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* 1. These last questions will help us combine your answers with those of others.In what ZIP code is your home located?

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* 2. What do you feel are the 3 most important social problems in your community? (Please check three boxes)

Question Title

* 3. And what do you feel are the 3 most important health problems in your community? (Please check three boxes)

Question Title

* 4. What do you feel are the top 3 reasons why obesity is an issue in your community? (Check three boxes)

Question Title

* 5. Which of the following make it harder for you and your household members to get health care services? (Check all that apply)

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* 6. Which of the following make it harder for you and your household members to get mental health services, such as counseling for loss, divorce, stress, depression, substance abuse or other issue? (Check all that apply)

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* 7. How would you rate health care services available to you in Northwest Indiana? (Check one box)

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* 8. How would you describe your overall health? (Check one box)

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* 9. Was there a time within the past year that you did not purchase or took less of a prescription medication because you could not afford it?

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* 10. Do you have a primary care doctor?

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* 11. If no, what is the main reason you do not have a primary care doctor? (Check only one box)

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* 12. When you need healthcare, where do you usually go for services? (Please check one box)

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* 13. For each type of care below, please tell us where you and members of your household primarily go to receive it by checking the box that best applies to you.

Question Title

* 14. In column A below, please tell us whether you or someone in your household has been diagnosed with any of the conditions listed. (Check all that apply)In Column B, please check the box beside each condition that has limited or caused major impairment to your lifestyle. (Check all that apply)

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* 15. In the past 12 months have you or anyone in your household visited the Emergency Room (ER) for any of the following? (Check all that apply)

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* 16. Have you or member of your household been the victim of physical violence in the past five years (domestic/street/gang/criminal violence?)

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* 17. Do you undergo the following preventive procedures on a regular basis? (Check the appropriate box for each item)

* 1. These last questions will help us combine your answers with those of others.
In what ZIP code is your home located?

* 14. In column A below, please tell us whether you or someone in your household has been diagnosed with any of the conditions listed. (Check all that apply)
In Column B, please check the box beside each condition that has limited or caused major impairment to your lifestyle. (Check all that apply)