Community Health Needs Assessment Survey

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* 1. What are your preferred appointment days?
Select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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* 2. What are your preferred appointment times?
Select all that apply

Early Morning (7:30-8:30am)

Morning (8:30am-12:00pm)

Early Afternoon (1:00-3:00pm)

Late Afternoon (3:00-5:00pm)

Early Evening (5:00-7:00pm)

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* 3. What do you usually do when you are sick Mondays to Fridays from 8:30am-5:00pm
Select all that apply

I do not seek healthcare

I go to the ER

I go to see my doctor

I use a virtual/telehealth appointment

I visit a mobile health unit

I go to urgent care

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* 4. What do you usually do when you are sick outside of Mondays to Fridays from 8:30am-5:00pm
Select all that apply

I do not seek healthcare

I go to the ER

I go to see my doctor

I use a virtual/telehealth appointment

I visit a mobile health unit

I go to urgent care

Question Title

* 5. What makes it hard to get healthcare for you, your family, or your friends?
Select all that apply

No challenges getting healthcare

Getting insurance / cost of insurance

Cost of medicine

Access to a doctor

Access to a dentist

Access to a therapist / counselor

Access to a doctor for pregnancy or reproductive support

Finding a doctor who I trust

Cost of healthcare

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* 6. Why do you usually go to the ER?
Select up to three

Emergency (injury)

Chest pain

Cold, cough, or fever

Tooth ache

Flare-up of a chronic condition (diabetes, asthma, sickle cell, etc.)

Other (please specify)

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* 7. How often did you go to the ER in the past 6 months?

No need to visit ER

2 times or less

3-5 times

More than 5 times

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* 8. Why do you have a hard time seeing the doctor?
Select all that apply

No transportation

No childcare

No insurance

No available doctor nearby

Could not afford co-pay

Hard to understand English

I’m busy when the doctor’s office is open

I don’t have enough time to visit the doctor

It’s hard to find a doctor who I trust

I don’t have a hard time visiting the doctor

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* 9. Are you able to see a therapist / counselor to support your behavioral health?

Yes

I do not need it

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* 10. If you could see (or currently see) a therapist / counselor, what needs would you want help with?
Select all that apply

Grief / loss support

Trauma

Depression

Anxiety

Drug / alcohol / substance use

Child Behaviors

I do not need a therapist / counselor

Other (please specify)

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* 11. What makes it hard to see a therapist / counselor?
Select all that apply

The doctor’s office is not open when I am available

I’m worried about what my family / friends will think

I can’t afford it

I don’t have behavioral health insurance

I don’t need a therapist / counselor

It’s not hard to see a therapist / counselor

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* 12. Are you able to visit the dentist when you need to?

Yes

I don’t go to the dentist

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* 13. What makes it hard to see a dentist?
Select all that apply

There are no available appointments for new patients

The dentist’s office is not open when I am available

I don’t have transportation to a dentist

I don’t have child care

I can’t afford it / don’t have dental insurance

It’s not hard to see a dentist

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* 14. Why do you go to the dentist?
Select all that apply

Regular cleaning / check-ups

Emergencies or pain

Different tooth issue / other

I don’t go to the dentist

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* 15. Where do you usually get your medicine from?

Giant Eagle on the North Side

Other grocery store

Drug store (such as Rite Aid or Walgreens)

Mail order

I sometimes can’t afford medicine

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* 16. Do you feel like you, your family, or your friends need care for any of the following?
Select all that apply

High blood pressure

High cholesterol

Diabetes

HIV / AIDS

Hepatitis C

Prefer not to answer

None

Other (please specify)

Question Title

* 17. What health care specialists do you need who are not currently available to you?

Skin doctor (dermatology)

Foot doctor (podiatry)

Pregnancy / reproductive health doctor (OB/GYN)

Eye doctor (ophthalmologist)

Bone, joint, and nerve care (chiropractor)

None

Other (please specify)

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* 18. How did you hear of North Side Christian Health Center?
Select up to three

I never heard of North Side Christian Health Center before getting this postcard

I’m a patient

Friend or family member

Question Title

* 19. Why don’t you go to North Side Christian Health Center?
Select all that apply

I'm a patient

I did not know about it

I see a different doctor / go to a different doctor’s office

I thought I had to be Christian to be a patient there

I’m worried that I’ll have to pray at my visit

I have insurance

It is too far from where I live or work

They are not open when I am available

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* 20. Is there anything else that you would like to share about getting healthcare for you, your family, or your friends?

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* 21. How old are you?

0 – 17 years old

18 – 40 years old

41 – 64 years old

65+ years old

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* 22. What is the primary language in your household?

English

Spanish

Arabic

Other (please specify)

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* 23. What best describes your race / ethnicity?
Select all that apply

Asian

Black or African American

Native American / American Indian or Alaska Native

White

White Hispanic

Non-white Hispanic

Prefer not to answer

Other (please specify)

Community Health Needs Assessment

Question Title

* 1. What are your preferred appointment days? Select all that apply

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* 2. What are your preferred appointment times? Select all that apply

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* 3. What do you usually do when you are sick Mondays to Fridays from 8:30am-5:00pm Select all that apply

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* 4. What do you usually do when you are sick outside of Mondays to Fridays from 8:30am-5:00pm Select all that apply

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* 5. What makes it hard to get healthcare for you, your family, or your friends? Select all that apply

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* 6. Why do you usually go to the ER? Select up to three

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* 7. How often did you go to the ER in the past 6 months?

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* 8. Why do you have a hard time seeing the doctor? Select all that apply

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* 9. Are you able to see a therapist / counselor to support your behavioral health?

Question Title

* 10. If you could see (or currently see) a therapist / counselor, what needs would you want help with? Select all that apply

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* 11. What makes it hard to see a therapist / counselor? Select all that apply

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* 12. Are you able to visit the dentist when you need to?

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* 13. What makes it hard to see a dentist? Select all that apply

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* 14. Why do you go to the dentist? Select all that apply

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* 15. Where do you usually get your medicine from?

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* 16. Do you feel like you, your family, or your friends need care for any of the following? Select all that apply

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* 17. What health care specialists do you need who are not currently available to you?

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* 18. How did you hear of North Side Christian Health Center? Select up to three

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* 19. Why don’t you go to North Side Christian Health Center? Select all that apply

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* 20. Is there anything else that you would like to share about getting healthcare for you, your family, or your friends?

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* 21. How old are you?

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* 22. What is the primary language in your household?

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* 23. What best describes your race / ethnicity? Select all that apply

* 1. What are your preferred appointment days?
Select all that apply

* 2. What are your preferred appointment times?
Select all that apply

* 3. What do you usually do when you are sick Mondays to Fridays from 8:30am-5:00pm
Select all that apply

* 4. What do you usually do when you are sick outside of Mondays to Fridays from 8:30am-5:00pm
Select all that apply

* 5. What makes it hard to get healthcare for you, your family, or your friends?
Select all that apply

* 6. Why do you usually go to the ER?
Select up to three

* 8. Why do you have a hard time seeing the doctor?
Select all that apply

* 10. If you could see (or currently see) a therapist / counselor, what needs would you want help with?
Select all that apply

* 11. What makes it hard to see a therapist / counselor?
Select all that apply

* 13. What makes it hard to see a dentist?
Select all that apply

* 14. Why do you go to the dentist?
Select all that apply

* 16. Do you feel like you, your family, or your friends need care for any of the following?
Select all that apply

* 18. How did you hear of North Side Christian Health Center?
Select up to three

* 19. Why don’t you go to North Side Christian Health Center?
Select all that apply

* 23. What best describes your race / ethnicity?
Select all that apply