2019 Community Health Needs Survey Question Title * 1. What county do you live in? Caroline Dorchester Kent Queen Anne's Talbot OK Question Title * 2. What is your zip code? OK Question Title * 3. What is your sex? Male Female OK Question Title * 4. Which one of the following is your race? Please check all that apply. American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Don't know Prefer not to answer Other (please specify) OK Question Title * 5. Are you Hispanic or Latino/a? Yes No Don't know Prefer not to answer OK Question Title * 6. On how many days during the past 30 days was your mental health not good? Mental health includes stress, depression and problems with emotions. Please write number of days. Zero days Don't know Prefer not to answer Days OK Question Title * 7. What are the three most important health problems that affect the health of your community? Please check only three Alcohol/Drug addiction Alzheimer’s/dementia Cancer Diabetes/high blood sugar Heart disease/blood pressure HIV/AIDS Infant death Lung disease/asthma/COPD Mental health (depression, anxiety) Overweight/obesity Smoking/tobacco use Stroke Don’t know Prefer not to answer OK Question Title * 8. What are the three most important social/environmental problems that affect the health of your community? Please check only three Availability/ access to doctors’ office Availability/access to insurance Child abuse/neglect Domestic violence Housing/homelessness Lack of affordable child care Lack of job opportunities Limited access to healthy food Limited places to exercise Neighborhood safety/violence Poverty Race/ethnicity discrimination School dropout/poor schools Transportation problems Don’t know Prefer not to answer OK Question Title * 9. What are the three most important reasons why people in your community do not get health care? Please check only three Cost- too expensive/can’t pay Cultural/religious beliefs No doctor nearby No insurance Insurance not accepted Lack of transportation Language barrier Wait is too long Don’t know Prefer not to answer OK Question Title * 10. What ideas or suggestions do you have to improve health in your community? OK Question Title * 11. To be entered into the $100 Amazon Gift Card Raffle, please leave your contact information below (Optional) Name Email Address Phone Number OK DONE
