Health Disparities Survey
1.
How do you define ‘health’?
State of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO)
The condition of being sound in body, mind or spirit. (Merriam Webster)
The absence of any disease or impairment. (NIH)
A state that allows the individual to adequately cope with all demands of daily life. (NIH)
A state of balance, an equilibrium that an individual has established within himself and between himself and his social and physical environment. (NIH)
2.
Choose which of the following you see on a regular basis? Check all that apply.
Family Doctor
Eye Doctor
Dentist
WIC Specialist
None
3.
The Covid pandemic has had the following impact on my life. Check all that apply.
Feelings of isolation.
Disagreement with family.
Change in how I shop.
Change how I get medical care.
Caused me to put off preventative health services, (PAP, mammograms, colonoscopy, doctors visits)
It did not change my life.
4.
I have the following:
Health insurance. (Private, Medicare, Medicaid)
No health insurance.
5.
Do you currently or have you driven out of the county to seek medical care due to unavailability?
Yes
No
6.
Check the top three (3) priorities that need addressed in Pettis Co:
Accessible and affordable food options.
Transportation
Accessible and/or affordable services for mental health.
Accessible and/or affordable childcare.
Accessible and/or affordable elder care.
Accessible and/or affordable housing.
Accessible and/or affordable addiction support.
Accessible and/or affordable shelters for abuse victims.
Accessible and/or affordable health care and prescription medicine.
7.
Age:
Under 18
18-24
25-34
35-44
45-54
55-64
65+
8.
Race:
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
9.
Gender:
Male
Female
Nonbinary
Transgender
10.
Zip Code:
65301
65302
65334
65337
65350
65360
65336
65333
65351
65332
65347
65345
65335
65325
65348
65340