2009 Community Health Needs Survey Spring
2009 Website: www.chca.us
Ÿ Email: healthy@chca.us
Your Age Group: ___ Under 18 ___ 19-34 ___35-54 ___55-64 ___65-74 ___75 or over
Do you currently have health insurance? ___Yes ___No
If
yes, is it: ___ Medicaid/KCHIP
___Medicare ___Private, employer assisted ___Private, I pay all costs
Seen a doctor in past 6 months?__ Yes __ No Been
hospitalized in the past year?__ Yes
___ No
Check if you: ___ Smoke ___ Are likely 20 lbs. overweight ___Exercise at least 20 min. most days
Do you currently owe more money to a
doctor/hospital than you can pay this year?
___Yes ___No
Are you a healthcare professional, or
employed in a health care environment? ___Yes
___No
1. What
do you consider to be our community’s most pressing health care issue? ______________
__________________________________________________________________________________
2. What is your FAMILY’s most pressing health
care issue? _________________________________
__________________________________________________________________________________
3. Have you experienced a problem/barrier to
getting health care in this community? __Yes
__No
If yes, what was it?
___________________________________________________________________
4. Please
check (ü) the
five (5) items that you believe to be the top health care related problems
facing our local community:
___ Unhealthy habits (smoking, lack of
activity and exercise, poor eating habits)
___ High number of uninsured and
underinsured people
___ Shortage of primary care doctors/people
without a primary doctor
___ Doctors not accepting
Medicaid/Medicare, or new Medicaid/Medicare patients
___ Use of the emergency room as the only
health care option for some
___ Cost of medical care
___ High cost of physician liability
insurance’s impact on availability of services
___ Cost of prescription medicines
___ Cost of medical insurance, co-pays and
deductibles
___ Difficulty in accessing psychiatric,
mental health or behavioral health services
___ Low income people feeling they are not
treated equally by the healthcare system
___ Difficulties with transportation to and
from medical services
___ Language barriers, other complications
in serving immigrants
___ Shortage of health care support
professionals (nurses, etc.)
___ Availability and accessibility to
appropriate pre-natal/pregnancy care
___ Difficulties in early identification
and intervention for early childhood disorders
___ Dental Care accessibility for those
without insurance or on Medicaid
___ Other (please list) ___________________________________________________________
5.
___ I agree that we need a new hospital and
the promised new services and benefits.
___ I question the need for a new hospital
and whether there will be benefits from it.
___ The public has been adequately informed
about the need for a new hospital.
___ The public does not understand
the need for a new hospital.
___ If building a new hospital was put to a
vote in this county, it would be endorsed or approved.
___ If building a new hospital was put to a
vote in this county, it would be turned down. Please offer comments, questions or
concerns about the proposed new hospital: ____________________
_____________________________________________________________________________________
Please
complete and return this form at this site, via email, by regular mail to the
above address, or fax to
Email:
_____________________________ Mailing Address _______________________________________________________