Community Health Needs Survey

  Question #1  
How would you describe your overall health?






Question #2  
Where do you go for routine healthcare?








Question #3  
If you marked "other" in question 2, please list where you go for routine healthcare.


Question #4  
Are you able to visit a doctor when needed?



Question #5  
If you answered "No" to question 4, please choose all that apply.







Question #6  
If you marked "other" in question 5, please list why you are not able to visit a doctor when needed.


Question #7  
What type of healthcare coverage do you have?






Question #8  
If you marked "other" in question 7, please list what type of healthcare coverage you have.


Question #9  
Please select the top 3 health challenges you face.














Question #10  
If you marked "other" in question 9, please list health challenges you face.


Question #11  
What additional health services need to be offered to meet health challenges in your community?


Question #12  
Please choose all statements below that apply to you.













Question #13  
Which of the following preventive procedures have you had in the past 12 months?

















Question #14  
What is your gender?



Question #15  
What is your county of residence?





Question #16  
If you marked "other" in question 15, please list what county you reside in.


Question #17  
What is your 5 digit zip code (Example 42701)?


Question #18  
What is your age?


Question #19  
What is your race?







Question #20  
What is your current employment status?








Question #21  
What is your household income range?







Question #22  
What is the highest level of education you have completed?





Question #23  
What can Hardin Memorial Health do to better meet the health needs of our community?