Community Health Survey

INSTRUCTIONS

We invite you to participate in the 2019 Oroville Hospital Community Health Survey, providing information about your health, the health of your family and health issues facing our community.

The survey will take about 5-10 minutes to complete and will help us identify the unique health-related concerns facing residents of Oroville and surrounding areas. It will also help us develop a series of resources and activities to address the needs identified.

This is an anonymous survey and we want to assure you that your responses will be kept strictly confidential. If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.

SECTION 1: ABOUT YOU AND YOUR FAMILY

Check the boxes that best apply for you, your spouse or partner, and/or your child(ren).    About how tall are you (without shoes)? Height:    About how much do you weigh (without shoes)? Weight:    How would you classify your gender identity? Gender: 


*Transgender Male refers to an individual that was assigned female at birth, and identifies as male. Transgender Female refers to an individual who was assigned male at birth, and identifies as female. If your identity is not listed above, please self-identify:    What is your home zip code? Zip Code:    Your age: Age:    What is your race? Race:    What is your marital status? Marital Status:    Are you currently employed? Employment:    Do you have a child or children under the age of 18? Child(ren):  If yes, what type of school is your child(ren) enrolled in? Type of school: 

If you checked "other", please explain.    What is the highest level of education you have completed? Education: If you checked "other", please explain.    What is your annual household income before taxes? Income:    How would you describe the overall health of each member of your family? Your Health: Your Spouse/Partner's Health: Your Child(ren)'s Health:    On average, how many days per week do you get at least 30 minutes of exercise or other physical activity?
EXAMPLES: walking, running, weight-lifting, team sports or gardening 
Exercise: You Exercise: Spouse/Partner Exercise: Child(ren)    What obstacles prevent you from getting regular exercise? Obstacles: If you checked "other", please explain.   Do you use, or have you used, any of the following substances? Alcohol: 

Cigarettes: 

Electronic cigarettes: 

Cigars, chew, or snuff: 

Cocaine: 

Crystal Methamphetamine (Meth): 

Heroin: 

Marijuana: 

Unprescribed prescriptions: 

   If you are a current or former smoker, are you aware of Oroville Hospital's smoking cessation program? Smoking cessation: Are you interested in joining the program? 

  

SECTION 2: ABOUT YOUR HEALTH AND HEALTH CARE

   Do you have a Primary Care Physician (PCP)? Your PCP: Your Spouse/Partner's PCP: Your Child(ren)'s PCP:   If you answered "yes" please list your doctor's name:    If you do not see a primary health provider regularly, please tell us why.
Check all that apply. 
No PCP: 



If you checked "other", please explain.    What other kinds of health care professionals do you visit regularly?
Check all that apply. 
Other HCP: You 



Other HCP: Spouse/Partner 



Other HCP: Child(ren) 



If you checked "other", please explain:    Where do you and your family members receive routine health care services? Your Healthcare: Your Spouse/Partner's Healthcare: Your Child(ren)'s Healthcare:    Did you have health insurance during all, part or none of the past year? Health Insurance You: Health Insurance: Spouse/Partner Health Insurance: Child(ren)    Currently, what is your primary type of health care coverage? Coverage: You Coverage: Spouse/Partner Coverage: Child(ren)    Which hospital do you normally go to for care? Hospital Hospital: If you checked other, please explain.   

FOR WOMEN, AGE 21 AND OLDER:

How long has it been since your last pap smear (a screening exam for cervical cancer)? Pap Smear:   

FOR WOMEN, AGE 40 AND OLDER:

How long has it been since your last mammogram (a screening exam for breast cancer)? Mammogram:   

FOR MEN, AGE 50 AND OLDER:

How long has it been since your last rectal exam (a screening used to examine the prostate)? Rectal Exam:  How long has it been since you had a prostate cancer screening blood test? Prostate Screening:   

FOR MEN AND WOMEN, AGE 50 AND OLDER:

How long has it been since your last colonoscopy (a screening exam for colon cancer)? Colonoscopy:  How long has it been since your last sigmoidoscopy (a screening exam for colorectal cancer)? Sigmoidoscopy:   

FOR EVERYONE:

Have you considered suicide? Suicide:    Do you have an advance care plan, living will or health care power of attorney? Advance Care Plan: You 

Advance Care Plan: Spouse/Partner 

Advance Care Plan: Child(ren) 

   Have you ever been told by a doctor or health care professional that you have any of the following conditions, diseases or challenges?
Check all that apply: 
Health Conditions: You 






If you checked "other", please explain: Health Conditions: Spouse/Partner 






If you checked "other", please explain: Health Conditions: Children 






If you checked "other", please explain:    Within the past year, what types of mental health services did you or anyone in your family use? Please select all that apply: 



If you checked "other", please explain. If you were in need of services, but were unable to access them, please explain why:    Do you feel that you have adequate access to quality health care? Please select one: 

If you feel you do not have adequate access, what is the biggest problem?
Please use the drop-down boxes to identify your 1st, 2nd, and 3rd choice. 
First choice: Second choice: Third choice: If you checked "other", please explain:    Where do you receive information about local health services?
Check all that apply: 
Information Access: 


   How would you prefer to receive health information?
Check all that apply: 
Information Receipt: 

  

SECTION 3: SOCIAL AND COMMUNITY CONTEXT

   Has anyone made you feel afraid for your personal safety or physically hurt you? Safety: If yes, what relationship is this person (or people) to you?    How often do you experience unwanted stress? Stress: 

   How satisfied are you with Oroville's school system? Satisfaction: 

If you are not satisfied, what do you think could be improved?
Please use the drop-down boxes to identify your 1st, 2nd, and 3rd choice. 
First choice: Second choice: Third choice: If you checked "other", please explain:    Do you feel that there are enough extra curricular activities available to children in Oroville and the surrounding communities? Activities: 

What improvements do you think would be beneficial?    Please use the drop-down boxes to identify your 1st, 2nd, and 3rd choice for each of the following:  Most important factors for a “Healthy Community” First choice: Second choice: Third choice: If you checked "other", please explain:    Greatest needs affecting “Children’s Health” First choice: Second choice: Third choice: If you checked "other", please explain:    Most important “Health Problems” facing our community First choice: Second choice: Third choice: If you checked "other", please explain:    Most challenging “Risky Behaviors” facing our community First choice: Second choice: Third choice: If you checked "other", please explain:   

SECTION 4: NEIGHBORHOOD AND BUILT ENVIRONMENT

   Do you feel that you have adequate access to affordable and healthy food? Access to food: 

If you feel you do not have adequate access, why not?
Please use the drop-down boxes to identify your 1st, 2nd, and 3rd choice. 
First choice: Second choice: Third choice: If you checked "other", please explain:    Are you satisfied with your current housing situation? Housing: If no, why not?
Please use the drop-down boxes to identify your 1st, 2nd, and 3rd choice. 
First choice: Second choice: Third choice: If you checked "other", please explain:    Were you forced to relocate as a result of the recent Camp Fire? Relocated:    What resources do you think Butte County residents need post Camp Fire?
Pleases use the drop-down boxes to identify your 1st, 2nd, and 3rd choice. 
First choice: Second choice: Third choice: If you checked "other", please explain:    Do you feel safe in the environment that you live in? Safe environment: 

   What changes would you like to see made in order to improve the neighborhood you live in? Neighborhood 

If you checked "other", please explain:    Where did you learn about this survey? Survey Survey: If you checked other, please explain.   

IS THERE ANYTHING WE’VE OVERLOOKED?

Feel free to write in additional information you think we should know about the health of our community. Comment (1000 character limit):   

Thank you for your time!

Your anonymous responses will be used by Oroville Hospital to better serve the health needs of our community’s residents.

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