Rate the importance of the following components of health care delivery in our County. (Circle one number in each row)

	Very Important	Important	Not Important	Don't Know
Availability of physicians
Availability of nurses
Availability of other professionals (lab/x-ray/respiratory/physical therapy)
Availability of hospital services
Availability of pharmacy services
Reasonable distance to health care services
Availability of transportation to health care services
Adequacy of emergency care

What was the approximate date of your last visit to a clinic or doctor? (i.e. when you actually saw a physician)

What was the location of this last visit?

About how long would it take you to get from your home to the nearest hospital, by car?

For your last visit with a physician, which of the following categories contains your principle reason for the visit?

Emergency care
An acute problem—but no emergency (e.g. flu, sore throat, etc.)
Preventive care (e.g. exam, shots, etc.)
Other (list):

Is there one physician to whom you would normally go when you are sick or need attention for your health?

Yes
No

Where is your primary physician located?

In our county
Elsewhere

How would you rate your present health?

Excellent
Good
Average
Fair
Poor

This past year, how many days did you stay in bed for more than half the day because of illness of injury? (Do not include days spent in the hospital)

How many times have you of other members of your household used hospital inpatient (admitted to the hospital) services during the past 12 months?

None
1-2
3-4
5 or more
Don't know

Currently, how many members of your household require medical care at least four times a year for a serious disease or chronic condition?

Which of the following services have you used?

	Local	Non Local	Not Applicable
Physical Therapy
Family Planning
Personal Counseling
Home Health Care
Home Delivered Meals
Homemaker Services
Nursing Home
Emergency Medical Services
Ambulance Service
Hospital
Dietary Counseling
Physician/medical clinic
Eye care
Vaccination
Dentist
Hearing Test
Pharmacy
Alcohol/Drug treatment

How would you rate each of the following aspects of general health care systems (includes all services: medical, dental, etc.) in our local area?

	Excellent	Good	Fair	Poor	Don't Know
Quality of care
Concern for patient/client
Reasonable charges
Competent support staff
Ease in getting an appointment
Ability to be seen on short notice
Range of services provided
Waiting times at facilities
Nursing care
Adequacy of buildings
Emergency Care
Outpatient services
Hours of available service

Please check each program you or a member of your household are using now or would use if available locally.

Health Risk Appraisal
Exercise Program
Stop Smoking Programs
Alcohol Counseling
Weight Reduction Program
Diet Management
Stress Management
Accident Prevention Program

Are there any other programs you would like to have locally available?

IF you are insured, how adequate do you feel your insurance coverage is?

Very poor or non-existent
Poor
Okay
Good
Excellent

In the past 12 months, how has your insurance coverage changed?

No change
Not sure, began insurance coverage within last 12 months
Increased coverage
Decreased coverage
Cancelled coverage

Have you decided not to use medical services in the past 12 months because of high out-of-pocket (personal) costs?

Yes
No

Have you decided not to use dental services in the past 12 months because of high out-of-pocket (personal) )costs?

Yes
No

When you go to the local doctor or hospital, how do you usually get there?

Drive my own car
Ask a friend or family member to drive me
Other (specify):

Would you be interested in taking CPR classes if they were available in your area?

Yes
No

Would you be interested in taking basic first aid classes if they were available in your area?

Yes
No

Please list any health care services that you want, which are not available now but are needed in the community.

Workplace health services
Fitness program
Alcohol and Drug treatment
Stress reduction
Nutrition and Diet programs
First aid/CPR education
Podiatry
Orthopedic department
Other:

How should the community finance future hospital improvements?

Issue general obligation bonds
Seek private donations
Apply for grants
Issue general revenue bonds
By hospital operating funds
Don't know

Our hospital needs to invest in improving:

Emergency Room facilities
Obstetric services
Pediatric services
Inpatient rooms
Clinical visit rooms
Waiting areas
Administrative office space
Laboratories
Operating facilities
Treatment facilities

Many rural hospitals are facing severe financial difficulties. Which of the following would you recommend for these hospitals

Closure
Closure with emergency service available 24 hours a day 7 days a week
Remain open using local tax support
Don't Know
Other alternative (Please specify)

Community Health Questionnaire