This questionnaire will be completed by community joint partners and residents. This questionnaire will be focused on Community Health, Marketing, and Telehealth Services and will gather the concerns and priorities of community members. The responses will be used to guide a priority action planning event with joint partners and outreach efforts of the hospital. It should take approximately 5- 10 minutes to complete.
Community Health

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* 1. What are the three most pressing concerns in the community that impact health? (Select 3 that apply, and/or enter other reasons not listed)

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* 2. How long has it been since you received a routine checkup (not a visit for a specific illness)? 

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* 3. If your last visit for a routine checkup was 2 years or more ago, please explain why.

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* 4. Have you had any difficulties in getting needed prescriptions drugs prescribed by your physician(s)?

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* 5. If yes you had difficulties, please explain why.

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* 6. Do you exercise and/or participate in physical activity? Select only one answer.

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* 7. If you are unable to participate in physical activities and/or exercise on a regular basis, please explain why not.  

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* 8. What could the community do to help you to become more physically active?

If you or a household member has a health care need, do you have a:

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* 9. Doctor you can go to?

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* 10. Dentist you can go to?

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* 11. Mental health care specialist you can go to?

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* 12. Substance abuse counselor you can go to?

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* 13. If you or your household member has a health care need, are you aware that Allen Parish Community Healthcare can help find you a provider?

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* 14. Where do you learn about ways to live a healthier life? (Select all that apply, and/or enter other ways not listed)

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* 15. What are the greatest health education needs in our community? (Select all that apply, and/or enter other reasons not listed)

Marketing

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* 16. What are the three most important reasons for selecting your health care organization? (Select 3 that apply and/or enter other reasons not listed)

Telehealth Services

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* 17. What times would you find most convenient for using telehealth services? (Select all that apply)

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* 18. Please tell us anything else that might be helpful in providing convenient, affordable access to health care for you and your family using telehealth services. Thank you!

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $10,000,000 with 100% funded by HRSA/HHS and $0 amount and 0% funded by non-government sources. The contents are those of the authors(s) and do not necessarily represent the official views of, nor an endorsement by HRSA/HHS, or the U.S. Government.

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