Inova Health System Community Health Needs Assessment Survey

1. Would you say that in general your health is:

Excellent

Very good

Good

Fair

Poor

2. When do you see a medical doctor or nurse? (Please select all that apply.)

Regularly / routinely for annual exam, check-up, and / or preventive care

When I and/or a family member is ill / sick / not feeling well

Occasional visits as directed by a professional for the care of chronic disease (for example, diabetes, high blood pressure, heart disease, asthma)

Rarely

Never

3. Where or with whom do you and your family members receive routine medical care? (Please select all that apply.)

Free or low-cost clinic or health center

Urgent care facility or store-based walk-in clinic

Hospital emergency room

Provider of alternative medicine

Private medical professional (MD, APN, PA)

No routine medical care received

Other (please specify below)

4. Are you and all of your family members able to get needed care?

5. If you did not answer "Always" to question 4, why? (Please select all that apply.)

6. If you answered “Other” in question 5, please specify below:

7. Do you have a specific medical professional (physician, nurse practitioner, physician's assistant) that you see on a regular basis?

Yes

No

8. If you answered "No" to question 7, what do you do when you need care?

9. What do you think are the biggest health issues in your community? (Select up to 5.)

10. Please indicate if you or anyone in your family (Please select all that apply.):

* 11. Do you identify with any ethnic origin? (Please select all that apply.)

12. If you answered “Other” in question 11, please specify below:

* 13. What category best describes your race? (Please select all that apply.)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White / Caucasian

Declined

Unavailable / Unknown

Other (please specify below)

14. What language is spoken in your home most of the time?

15. How well do you know English?

Very well

Well

Not well

Not at all

16. How do you get information from the Inova Health System? (Please select all that apply.)

17. How would you prefer to get information about services available to you from the Inova Health System?

* 18. What is your gender?

Male

Female

* 19. How old are you?

20. Do you currently smoke or use tobacco?

Yes

No

21. Have you ever smoked?

Yes

No

22. Are you overweight?

Yes

No

23. Do you exercise on a regular basis?

Yes

No

24. Are your children or grandchildren overweight?

Yes

No

I do not have children or grandchildren.

25. In the last year, have you been screened for (Please select all that apply.):

High cholesterol?

High or low blood pressure?

High or low blood sugar?

Sexually transmitted infections?

26. Have you received the following vaccinations (Please select all that apply.):

Flu / influenza in the last year?

Hepatitis A?

Hepatitis B?

Human papillomavirus (HPV) before the age of 26?

Meningococcal?

MMR (measles, mumps, rubella) if you were born after 1957?

Pneumonia / pneumococcal?

Tdap (tetanus, diptheria, pertussis) every 10 years?

Varicella (chicken pox) if you've never had chicken pox?

25. In the last year, have you been screened for (Please select all that apply.):

Cervical cancer (Pap test)?

High cholesterol?

High or low blood pressure?

High or low blood sugar?

Sexually transmitted infections?

26. Have you received the following vaccinations (Please select all that apply.):

Flu / influenza in the last year?

Hepatitis A?

Hepatitis B?

Human papillomavirus (HPV) before the age of 26?

Meningococcal?

MMR (measles, mumps, rubella) if you were born after 1957?

Pneumonia / pneumococcal?

Tdap (tetanus, diptheria, pertussis) every 10 years?

Varicella (chicken pox) if you've never had chicken pox?

25. Have you been screened for (Please select all that apply.):

Colorectal cancer (colonoscopy) in the last 5 years?

High cholesterol in the last year?

High or low blood pressure in the last year?

High or low blood sugar in the last year?

Prostate cancer in the last year?

Sexually transmitted infections in the last year?

26. Have you received the following vaccinations (Please select all that apply.):

Flu / influenza in the last year?

Hepatitis A?

Hepatitis B?

Meningococcal?

Pneumonia / pneumococcal?

Tdap (tetanus, diptheria, pertussis) every 10 years?

Varicella (chicken pox) if you've never had chicken pox?

Zoster (shingles) if you are age 60+?

25. Have you been screened for (Please select all that apply.):

Breast cancer (mammogram) in the last year?

Cervical cancer (Pap test) in the last year?

Colorectal cancer (colonoscopy) in the last 5 years?

High cholesterol in the last year?

High or low blood pressure in the last year?

High or low blood sugar in the last year?

Sexually transmitted infections in the last year?

26. Have you received the following vaccinations (Please select all that apply.):

Flu / influenza in the last year?

Hepatitis A?

Hepatitis B?

Meningococcal?

Pneumonia / pneumococcal?

Tdap (tetanus, diptheria, pertussis) every 10 years?

Varicella (chicken pox) if you've never had chicken pox?

Zoster (shingles) if you are age 60+?

27. With which religious group are you affiliated?

28. What is your relationship status?

29. What is your employment status?

30. What type of health insurance (primary) do you have?

No health insurance

Medicaid

Medicare

Private / commercial insurance

I have insurance through my job (employer-sponsored coverage).

Other (please specify)

* 31. What is your ZIP code?

32. What is the best thing that has happened in healthcare where you live?

33. Do you have any comments or feedback?

Inova CHNA Survey