Community Health Needs Assessment Survey

The Purchase Area Health Connections is assisting with Community Health Needs Assessments. Please fill out the following survey questions to help us identify the community's needs.

The survey should take 5-10 minutes. All responses are anonymous.
1.How old are you?
2.Identify your gender:
3.Identify your race. (Check all that apply)
4.If you have insurance, what is your status?
5.What county do you live in?
6.Identify your primary transportation:
7.What risk factors affect your personal health? (Check all that apply)
8.Identify the health challenges you face. (Check all that apply)
9.Are there barriers that prevent you from accessing health care? (Check all that apply)
10.What factors influence your health choices? (Check all that apply)
11.Where do you get most of your healthcare information? (Check all that apply)
12.Do you and your family get any of the following regular health screenings or vaccines? (Check all that apply)
13.What is your barrier to the recommended weekly physical activity (30 minutes of moderate (walking at a fast pace) exercise, 5 times a week)? (Check all that apply).
This graphic will assist you in answering the next question.
14.According to the American Heart Association, a person should consume 4 servings of fruit and 5 servings of vegetables per day. What are your barriers to the recommended daily consumption of fruits and vegetables? (Check all that apply).
15.What type of treatment and/or supports have you utilized for substance use disorders/mental health in the past 12 months? (Check all that apply).
16.Is your community a good place to...
Yes
No
Raise Children?
Retire?
Live?
17.Are you currently...
18.What major issues does the community need to address? (Check all that apply).
19.How has the COVID pandemic impacted your life? (Check all that apply).