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Houston Methodist is conducting a Community Health Needs Assessment for its community service area. The information collected in this survey will allow organizations across our region to better understand the health needs in our community. The knowledge gained will be used to implement programs that will benefit everyone in the community. We can better understand needs by gathering the voices of community members like you to tell us about the issues that you feel are the most important. Please take a moment to complete the following questionnaire.


The responses that you provide will remain anonymous and your participation in this survey is voluntary.

To thank you for taking the time to do this survey, you will have the option to enter a raffle to win Astros tickets. The contact information you share to enter the raffle will be kept separate from your anonymous survey answers.
For questions about this questionnaire, email chna@houstonmethodist.org

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* 1. Gender Identity: What gender do you feel you most identify with?

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* 2. Age: What age range do you fall within?

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* 3. Ethnicity: Which ethnicity do you most identify with?

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* 4. Race: What race do you classify yourself as?

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* 5. Language: What language is most spoken in your household?

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* 6. Sexual Orientation:

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* 7. Employment: What is your employment status?

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* 8. Education: What is your highest education level?

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* 9. Household Residents: Number of people living in the Household including yourself:

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* 10. Household Income: Please select the range that includes the income of all persons living within your household

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* 11. Marital Status: Are you married? (Common law marriage or living as married couple is considered married)

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* 12. Health Coverage: If any, please indicate the type of health insurance you have:

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* 13. Residing Zip Code:

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* 14. Residing County:

Tell Us About Your Health

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* 15. How would you rate your overall health?

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* 16. Tobacco Use: Do you Smoke, Vape, or Chew Tobacco?

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* 17. Alcohol Use: Please tell us how you would rate your overall drinking habits?

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* 18. Exercise: Do you exercise for a total of 2.5 hours or more per week?

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* 19. Diet and Nutrition: On a scale of 1 to 5, how would you rate your eating habits or diet?

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* 20. What are the top THREE biggest barriers that prevent you from eating healthy foods? (Select top 3)

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* 21. What are the primary health conditions you currently feel are most negatively impacting your health? (Select all that apply)

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* 22. What are the top THREE biggest barriers that prevent you or your immediate family from seeking ANY medical treatment? (Select top 3)

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* 23. Which of the following health screenings have you had in the past 12 months? (Select all that apply)

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* 24. Do you have a primary care physician?

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* 25. When is the last time you visited your primary care physician?

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* 26. What are the barriers that prevent you or your immediate family from seeing a Primary Care Physician? (Select all that apply)

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* 27. Have you ever been referred to see a Specialist? (Example: Cardiology, Oncology, Endocrinology, Neurology, etc.)

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* 28. If yes, did you follow through and see the specialist?

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* 29. If no, why not? (Select all that apply)

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* 30. What kind of place do you usually go if you are sick and need healthcare?

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* 31. During the past 12 months, how many times have you gone to a hospital emergency room about your health? (This includes visits that resulted in hospital admission)

During the past 12 months, were any of the following true for you?

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* 32. At any time in the last 12 months, did you take prescription medication?

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* 33. You skipped medication doses to save money.

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* 34. You took less medication to save money.

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* 35. You DELAYED filling a prescription to save money.

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* 36. During the past 12 months, was there any time when you needed prescription medication, but DID NOT GET IT because of the cost?

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* 37. Select the top THREE areas where you get most of your health information?

Tell Us About Your Community and Social Experiences

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* 38. From the following list, what do you think are the THREE most important factors for a “Healthy Community?” (Those factors which most improve the quality of life in a community.)

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* 39. In the following list, what do you think are the THREE most important factors negatively impacting your community? (Select top three)

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* 40. Which top THREE non-medical social services do you think are most needed in the community right now? (Select top 3)

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* 41. During the past 12 months, have you and/or your immediate family DELAYED getting medical care because of the cost?

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* 42. During the past 12 months, was there any time you and/or your immediate family needed medical care, but DID NOT GET IT because of the cost?

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* 43. How true is the following statement for your household in the last 12 months?: “I worried whether our food would run out before we got money to buy more.”

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* 44. How true is the following statement for your household in the last 12 months?: “The food you bought just didn’t last and you didn’t have money to get more.”

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* 45. How true is the following statement for your household in the last 12 months?:
“You could not afford to eat healthy meals.”

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* 46. How true is the following statement for your household in the last 12 months?: "I have you been worried or concerned about not being able to afford to pay my rent/mortgage?"

Tell Us About Your Transportation

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* 47. In the past 12 months, has a lack of reliable transportation kept you from medical appointments, meetings, work, or getting things you needed for daily living?

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* 48. Within the last year, have you ever missed an appointment or been unable to obtain needed healthcare because of problems with your transportation?

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* 49. If yes, what was the reason(s) you could not get to the clinic? (Select all that apply)

Tell Us How You Feel

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* 50. Overall, how would you rate your mental health?

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* 51. Have you ever been diagnosed with a mental health disorder before e.g. bipolar disorder, anxiety, depression, PTSD, etc.?

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* 52. Mental health is just as important as physical health.

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* 53. During the past 12 months, was there any time when you felt you would benefit from mental health care or counseling support?

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* 54. During the past 12 months, was there anytime when you needed counseling or therapy from a mental health professional, but DID NOT GET IT because of the cost?

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* 55. Do you know how to access mental health care if you or a family member needed it?

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* 56. What are the top THREE biggest barriers that prevent you and/or your immediate family from seeking mental health services?

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