Community Needs Assessment

Thank you for taking part in this important survey!

Hilltown Community Health Center (HCHC) is conducting a Community Needs Assessment Survey to better understand the needs of our community and our patients. Our mission is to create access to high quality accessible health care and promote well-being for individuals, families, and our communities. We’d like to find out how you feel about the most important health needs in your community so that we can do so effectively.

This survey should only take 5-7 minutes to complete.

We want to assure you that your responses are completely anonymous. Responses to anonymous surveys cannot be traced back to the respondent. No personally identifiable information is captured unless you voluntarily offer personal or contact information in any of the comment fields. Additionally, your responses are combined with those of many others and summarized in a report to further protect your anonymity.

Eliza Lake, CEO

Question Title

* 1. What are the biggest health issues or concerns in your community? (Check all that apply)

Asthma/lung disease

Cancer

Diabetes

HIV/AIDS

Heart disease

Mental health/depression/suicide

Addiction

Stroke

Oral health/dental care

I don't know

Other (please specify)

Question Title

* 2. What keeps people in your community from seeking treatment for medical or dental needs? (Check all that apply)

Lack of insurance

Unable to pay co-pays

Health services too far away

Cultural or religious beliefs

Fear (Not ready to face a health problem)

Don't understand the need to see a medical provider

Don't understand the need to see a dentist

Lack of transportation

Lack of child care

Too long of a wait at the provider's office

Too long of a wait to get an appointment to see medical provider

No access to a primary care provider/ PCP

No access to a dentist

Language barrier/ does not speak my language

Don't know how to find provider

None/no barrier

I don't know

Other (please specify)

Question Title

* 3. Please select the top three health challenges you face.

Cancer

Diabetes

Overweight/obesity

Lung disease

High blood pressure

Stroke

Heart disease

Joint pain or back pain

Mental health issues

Alcohol overuse

Drug addiction

I do not have any health challenges

Other (please specify)

Question Title

* 4. Which of the following are needed to improve the health of your family and neighbors? (Check all that apply)

Healthier foods

Job opportunities

Mental health services

Recreation facilities

Transportation

Wellness services

Specialty physicians

Safe place to walk/ play/ exercise

Addiction treatment

I don't know

Other (please specify)

Question Title

* 5. What health screenings or education/ information services are needed in your community? (Check all that apply)

Cancer

Cholesterol

Blood pressure

Heart disease

Diabetes

Dental screenings

Disease outbreaks

Substance abuse disorder

Nutrition/ healthy eating

Exercise/ physical activity

Emergency preparedness

Eating disorders

Falls prevention

HIV/ sexually transmitted diseases

Mental health

Vaccination/ immunizations

Prenatal care

Domestic violence

Other (please specify)

Question Title

* 6. If you or someone in your family were ill and required medical care, where would you go? (check one)

Private Primary Care Provider's (PCP) office

Clinic

Hospital emergency department

Urgent Care/Walk-in center

Health department

PCP at a Community Health Center

Would not seek care

Other (please specify)

Question Title

* 7. Where do you and your family get most of your health information? (Check all that apply)

PCP/ health professional

Family or friends

Health Department

Hospital

Internet

Library

Newspaper/Magazines

Radio

Religious organization

School

Social Media

Television

Other (please specify)

Question Title

* 8. Please choose all statements below that apply to you.

I exercise at least three times per week

I eat at least five servings of fruits and vegetables each day.

I eat fast food more than once per week.

I smoke cigarettes.

I chew tobacco.

I do not use illegal drugs.

I use marijuana.

I vape.

I abuse or over use prescription drugs.

I have more than four alcoholic drinks (if female) or five (if male) per day.

I use sunscreen or protective clothing for planned time in the sun.

I receive the flu shot each year

I have access to a wellness program through my employer

None of the above apply to me.

Question Title

* 9. Which of the following preventive procedures have you had in the past 12 months?

Mammogram (if have breasts)

Pap smear (if have uterus)

Prostate cancer screening (if have prostate)

Flu shot

Colon/rectal exam

Blood pressure check

Blood sugar (A1C) check

Skin cancer screening

Vision screening

Hearing screening

Cardiovascular screening

Bone density test

Dental cleaning

Physical exam

None of the above.

Question Title

* 10. Have you had a routine physical exam in the past two years?

Yes

Question Title

* 11. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 11363 or 94305)

Question Title

* 12. Are you enrolled in health insurance?

Yes (Please skip to Question 15 below)

No (Please answer Question 13 below)

Question Title

* 13. If not, when did you last have health insurance?

<6 mos. ago

6 mos.-1 year ago

>1 year ago

Question Title

* 14. If not, why do you not have insurance? Check all that apply.

Too expensive

Not eligible

Not available through employer

Missed enrollment period

Application process too hard to complete

Concern about effect on immigration status

Language barriers

Question Title

* 15. What is your current gender identity?

Male

Female

Decline to answer

Transgender Male

Transgender Female

Additional gender category/ Other (please specify)

Question Title

* 16. What category below includes your age?

Under 18

18-29

30-39

40-49

50-59

60-69

70-79

80-89

90+

Question Title

* 17. How would you describe yourself by race? You may select more than one option.

White/Caucasian

Black/African American

Asian

Native American

Alaskan Indian/ Alaskan native

Pacific Islander

Other (please specify)

Question Title

* 18. What is your ethnic identification?

Hispanic

Non-Hispanic

Question Title

* 19. What is your annual household income?

<$25,000

$26,000-$49,000

$50,000-$99,000

$100,000-$200,000

>$200,000

Thank you for your participation!