Black Health Matters' COVID-19 Questionnaire

Provided by Black Health Matters

This survey is designed to learn more about the feelings and experiences of people in the Black community around a wide variety of symptoms.

This is an anonymous survey that is being conducted by Black Health Matters in an effort to provide you with more useful content and resources online and in your community.

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* 1. What age group do you belong to?

18-34

35-49

50-64

65+

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* 2. What is your gender?

Male

Female

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* 3. How many children, ages 0 to 17, live in your household?

1-2

3-4

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* 4. What is your household income?

Under $15,000

Between $15,000 and $25,000

Between $26,000 and $40,000

Between $41,000 and $60,000

Between $61,000 and $75,000

Between $76,000 and $100,000

Between $100,000 and $150,000

Over $150,000

Unemployed

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* 5. Using the numbers 1- 5, with 1 being most important and 5 being least important, please rank what you think are the most important ways to promote health and wellness for all Black Americans at this critical time:

	1	2	3	4	5
Increasing community awareness of mental health services	Increasing community awareness of mental health services 1	Increasing community awareness of mental health services 2	Increasing community awareness of mental health services 3	Increasing community awareness of mental health services 4	Increasing community awareness of mental health services 5
A study to understand the specific health needs of all Black Americans	A study to understand the specific health needs of all Black Americans 1	A study to understand the specific health needs of all Black Americans 2	A study to understand the specific health needs of all Black Americans 3	A study to understand the specific health needs of all Black Americans 4	A study to understand the specific health needs of all Black Americans 5
Providing services, brochures, and other health information to churches in the community	Providing services, brochures, and other health information to churches in the community 1	Providing services, brochures, and other health information to churches in the community 2	Providing services, brochures, and other health information to churches in the community 3	Providing services, brochures, and other health information to churches in the community 4	Providing services, brochures, and other health information to churches in the community 5
More efforts to address domestic and community violence	More efforts to address domestic and community violence 1	More efforts to address domestic and community violence 2	More efforts to address domestic and community violence 3	More efforts to address domestic and community violence 4	More efforts to address domestic and community violence 5
Promoting more cultural and family health information to families	Promoting more cultural and family health information to families 1	Promoting more cultural and family health information to families 2	Promoting more cultural and family health information to families 3	Promoting more cultural and family health information to families 4	Promoting more cultural and family health information to families 5

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* 6. In the space provided, please suggest other health actions or ideas you think should be a part of the Black Health Matters platform.

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* 7. How often do you get a health checkup?

Every 3 months

Every 6 months

Once a year

Only when needed

Never

Other (please specify)

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* 8. Overall, how do you rate your experiences with your doctor/advanced practice provider?

Very Poor

Poor

Average

Above Average

Excellent

Very Poor

Poor

Average

Above Average

Excellent

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* 9. Overall, how do you rate your hospital or clinic?

Very Poor

Poor

Average

Above Average

Excellent

Very Poor

Poor

Average

Above Average

Excellent

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* 10. How do you rate your overall health? Would you say you are:

In good physical health (no illness or disability)

Mildly sick (minor illness or disability)

Moderately sick (require substantial treatment)

Severely sick (require extensive care)

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* 11. Are you a caregiver?

Yes

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* 12. Are you currently suffering from an illness or chronic disease?

Yes

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* 13. Are you taking any prescription medications?

Yes

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* 14. If you answered "yes" to the previous question, approximately how many different prescription medications do you take per week?

1-2

3-5

6-8

9-11

12-20

21+

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* 15. Do you have any hereditary conditions?

Yes

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* 16. If you answered "yes" to the previous question, please select all that apply.

High blood pressure

Diabetes

Hemophilia

Sickle Cell Disease

Heart Disease

Kidney Disease

Other (please specify)

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* 17. Do you currently, or have you ever, had cancer?

Yes

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* 18. If you answered "yes" to the previous question, please select all that apply.

Breast

Prostate

Ovarian

Uterine/Endometrial

Lung

Other (please specify)

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* 19. How worried are you about the impact of Coronavirus (COVID-19) on you and your family?

Extremely

Very

Mildly

Not

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* 20. Given the current situation, rate how comfortable you would be doing the following, using the numbers 1-5 (1 being extremely uncomfortable and 5 being extremely comfortable).

	1	2	3	4	5
Visiting your doctor if you feel symptoms of COVID-19	Visiting your doctor if you feel symptoms of COVID-19 1	Visiting your doctor if you feel symptoms of COVID-19 2	Visiting your doctor if you feel symptoms of COVID-19 3	Visiting your doctor if you feel symptoms of COVID-19 4	Visiting your doctor if you feel symptoms of COVID-19 5
Going to a test center if you feel symptoms of COVID- 19	Going to a test center if you feel symptoms of COVID- 19 1	Going to a test center if you feel symptoms of COVID- 19 2	Going to a test center if you feel symptoms of COVID- 19 3	Going to a test center if you feel symptoms of COVID- 19 4	Going to a test center if you feel symptoms of COVID- 19 5
Calling the ER and going to a hospital	Calling the ER and going to a hospital 1	Calling the ER and going to a hospital 2	Calling the ER and going to a hospital 3	Calling the ER and going to a hospital 4	Calling the ER and going to a hospital 5
Staying at home	Staying at home 1	Staying at home 2	Staying at home 3	Staying at home 4	Staying at home 5

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* 21. What is your primary source of news about COVID-19?

Facebook

Twitter

Black Health Matters

The Center for Disease Control (CDC)

Friends and Family (word of mouth)

Other Websites

CNN

MSNBC

Local News

City or Country Website

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* 22. Do you know if anyone in your family has been exposed to COVID-19?

Yes

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* 23. Do you know of anyone who has succumbed to COVID-19?

Yes

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* 24. Are you participating in social distancing?

Yes

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* 25. Which health care insurance, if any, do you currently have?

Private insurance

Work insurance

Affordable Care Act

Medicaid

Medicare

Not Insured

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* 26. Are you registered to vote?

Yes

I am unable to vote

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* 27. Will you vote in the current presidential election?

Yes