St. Francis Hospital & Health Services Community Health Needs Assessment
Answers marked with a * are required.
1. In general, how would you rate your overall health? (select one) *

2. The recommendation for physical activity is 30 minutes a day 5 days a week (2.5 hours per week).  Which of the following reasons prevent you from gettting this much physical activity? (select all that apply) *

3. One recommendation to maintain a healthy lifestyle is to eat atleast 5 servings of fruits and vegtables a day (not french fries or potatoe chips).  Which would you consider the main reason that you do not eat this way. (select one) *

4. Have you visited a doctor (primary care) in the past 12 months? *


5. Have you visited a specialist (OBGYN, dermatologist, allergist, etc.) in the past 12 months?


6. Where do you go most often for health care when you are sick?


7. Where do you go when you need your yearly check-up or physical? (select all that apply) *

8. was there a time, in the past 12 months, where you needed to see a doctor, but didnt? If yes, why didnt you see a doctor?

9. Select the diseases, challengaes or conditions that you have been diagnosed with by a health care provider. (select one)

10. Do you feel that you have what you need to manage these conditions?
What do you feel you need to help you manage these conditons?

11. Which of the following are the top 5 things that impact health in our community? (Select up to 5)

12. Select the diseases, challenges or conditions that you think are a concern for our commnity. (select all that apply)

13. What are our major strengths/resources in our community related to health care?
14. What resources could be used differently to improve health care?
15. Please select the highest level of education you have completed.

16. Please select the option that best describes your health insurance provider.

17. Race/Ethnicity (check all that apply)

18. what is your average annual household income?

19. what is your age?

20. What is your gender?
21. What is your zip code?

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