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Community Health Needs Assessment

If you are at least 18 years of age, please complete the following survey, one per household. All survey respondents will remain anonymous. Do not include your name or other identifiers on the survey.

1. Your current health status: 

2. Select the type(s) of insurance you
currently have (Check all that apply): 

3. Select your current type of health insurance: 

4. Number of days you have been too sick
to work or carry out your usual activities
in the past 30 days: 

5. Your last routine (scheduled) doctor's visit: 

6. Select any of the following preventative
procedures you had in the last year:
(Select all that apply) 

7. Are you able to visit a doctor when needed? 

8. Where do you go for routine (scheduled)
health care visits? (Select all that apply) 

9. If you answered never to No. 7, select why: 

10. Do you travel outside of Tarrant
County for medical care? 

11. If you travel outside of Tarrant
County for medical care, select the
services you seek: (select all that apply) 

12. If you travel outside of Tarrant
County for medical care, why? 

13. Sources where you obtain most
health related information:
(select all that apply) 

14. Does your employer offer health promotion
or wellness programs? 

15. If your employer offers health promotion
wellness programs, do you participate? 

16. In the past 30 days have you ridden
with a driver who had been drinking? 

17. In the past 30 days, have you driven
after drinking one or more alcoholic beverages? 

18. City in which you live: 

19. Length of time you have been a
resident in your current city: 

20. Zip Code: 
21. Your Sex: 

22. Your racial/ethnic identification: 

23. Your current age: 

24. County in which you work: 

25. Your highest level of
education completed 

26. Your employment status: 

27. Your yearly household income: 

-------------------- ABOUT YOU: In the following section, select which answer best describes you. --------------------  
You wear a seat belt: 
You wear a helmet when riding a
bicycle/motorcycle, rollerblading
or skateboarding: 
You eat at least 5 servings of
fruit and vegetables a day: 
You eat fast food (McDonald's, etc.)
more than once a week: 
You exercise at a medium pace at least
30 minutes per day,
five days per week: 
You consume more than three alcoholic
drinks per day (female) or more than
five per day (Male): 
You smoke cigarettes or are around
people who smoke: 
You chew tobacco: 
You use illegal drugs (marijuana, cocaine, etc.): 
You perform self exams for cancer
(breast or testicular): 
You wash your hands with soap
and water after using the restroom: 
You apply sunscreen before planned time outside: 
You get a flu shot each year: 
You practice safe sex with a condom
or other barrier (method): 
You feel stressed out: 
You worry about losing your job: 
You feel safe in your community: 
------------ COMMUNITY ISSUES: Please tell us your thoughts about community issues and concerns. ------------ 
Air pollution: 
Alcohol/Drug Use: 
Asthma and other Respiratory Disorders: 
Eating Disorders (Bulimia or Anorexia): 
Child Care/Day Care: 
Child Abuse: 
Domestic violence: 
Elder abuse: 
Elder Day Care: 
Gang Activity: 
Health Care Affordability/Availability: 
Heart Disease: 
High Blood Pressure/Strokes: 
Highway Safety: 
Housing Affordability: 
Infant Health: 
Infectious Disease (menningitis): 
Job Security/Availability: 
Mental Illness: 
Nursing Home Care: 
Overweight Adults: 
Overweight Children: 
Prenatal Health: 
Services for Disabled: 
Sexually Transmitted infections: 
Smoking/Secondhand Smoke/Smokeless Tobacco: 
Swimming Facilities (Safe/Sanitary): 
Teen Pregnancy: 
Transportation (Public): 
Thank you for assisting us in improving the health of the people in
the communities that we serve. Your input is important and will be kept confidential. 
As a token of appreciation, you can now choose to enter your name in a prize drawing
for an iPad by sending an email to: 
Winner will be notified the week of May 15, 2012.  

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