Thank you for taking the time to answer the below survey questions. Legacy Community Health is conducting this survey to find out how you feel about your health and your current or past health care providers. The information gathered today is confidential, is anonymous and will not be used outside of our agency. The results of the survey will be used to help us improve how we provide health care and wellness services.

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* 1. What grade are you in:

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* 2. Name of School:

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* 3. What zip code do you live in:

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* 4. What age group do you belong to?

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* 5. At what age do you think you should be fully in charge of your healthcare?

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* 6. What is your race or ethnicity? (Check all that apply)

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* 7. Gender: How do you identify?

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* 8. What level of education do your parents/guardians have?

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* 9. How do you (or parent/guardian) typically pay for health care visits? (Check one)

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* 10. Describe what wellness means to you in one sentence.

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* 11. What do you worry about the most right now?

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* 12. What of the below topics do you worry about at some level?

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* 13. Who do you go to most often with your health questions?

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* 14. What health and wellness concerns do you want to talk to a doctor/health care provider about?

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* 15. How would you rate your physical overall health? (Check one)

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* 16. How would you rate your mental overall health? (Check one)

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* 17. When do you typically go to a doctor or health care provider? (Check all that apply)

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* 18. How often do you visit a health care provider in one year? (Check one)

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* 19. Who is involved in making decisions about your health care? (Check all that apply)

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* 20. What type of health care services have you received in the past 6 months? (Check all that apply)

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* 21. Are there reasons you may not go to see a doctor? (Check all that apply)

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* 22. Where do you normally receive health care? (check one)

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* 23. Do you make your own health care appointments, and if yes, how do you prefer to do so?

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* 24. How do you prefer to communicate with your health care provider (talk to your doctor, ask questions, etc)? (check one)

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* 25. What could your doctor/health care provider do to make your experience more positive?

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* 26. Legacy Community Health has a program and website dedicated to teen health called TeenWell. How familiar with the TeenWell program are you?

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* 27. Thank you for taking this survey! All responses above are confidential and anonymous. The questions below are separate and the information will only be used for prize entry and/or group discussion participation.


If you would like to be entered in a chance to win one of ten $25 Visa gift cards, please enter your email address here:

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* 28. Legacy has opportunities for you to become more involved in health care. Please enter your telephone number and email address below if you would like to be contacted for participation in either of these opportunities.
- If you would like to participate in a focus group discussion about your health and health care preferences.
- If you would like to become a Teen Health Ambassador. 


Please note that for all those under 18 years of age, we will need parent/guardian consent to participate (a form will be emailed asking for parent/guardian permission). Group discussions will be offered both virtually and in-person. All participants will receive a $25 Visa gift card for their time, and entered in a chance to win prizes.

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