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Mizell Memorial Hospital

Community Health Needs Assessment

Thank you for taking the time to provide us with information about your healthcare needs.

We appreciate your time and cooperation.
  Do you make the majority of the healthcare decisions in your household, such as which hospitals and doctors to use for medical care?
  What is the zip code where you live?
  My age:
  I am:
  Health insurance coverage:
  My race:
  Employment status:
  My annual household income:
  What is your highest level of education completed?
  Do you have any children under the age of 18 living with you?
  Do you have an elderly relative living with you?
  What do you consider your current health status to be?
  Where do you go for routine health care?
  Have you had a physical examination by your physician in the past year?
  Do you consider your weight to be?
  Select any of the following with which you have been diagnosed: Diabetes
High blood pressure
Cardiovascular (heart) disease
Respiratory disease (Asthma/etc.)
Chronic pain (Back/arthritis/etc.)
Other (please specify below)
  Have you been diagnosed with cancer in the past five years?
  Have you been a patient in an emergency room in the past year?
  Have any of your dependents been in an emergency room in the past year?
  Did a lack of transportation prevent you from receiving medical care in the past year?
  Did the cost of care prevent you from seeking medical care in the past year?
  Do you smoke or use smokeless tobacco?
  Does anyone in your home smoke?
  If you are a woman over the age of 40, have you had a mammogram in the past year?
  If you are a woman over the age of 21, have you had a pap smear in the past year?
  If are you employed, did you miss more than 10 days of work last year due to illness?
  Do you routinely exercise?
  Do you routinely use the stairs instead of riding the elevator?
  When parking your car, do you try to park in the nearest parking space to the door?
  Do you suffer from depression?
  Have you been diagnosed with a mental illness?
  Do you drink alcohol daily?
  Do you use sunscreen when you are out in the sun for an extended time?
  Do you use a seat belt when you are driving or traveling in a car?
  How many servings of fruits and vegetables do you eat each day?
  In your opinion, please select the 3 items below that represent the most important health issues in our community: Access to medical care
Cost of care
Use of illegal drugs
Mental health issues (including Dementia and related conditions)
Heart and Stroke (blood pressure)
Obesity and related issues (diabetes)
Use of tobacco products
Sexually transmitted diseases (STD's)
Children's illnesses
Cancer and related illnesses
  If you needed hospital care, which hospital in the area would you prefer to use?
  In the past year, have you or has any member of your household spent one night or more as a hospital inpatient?
This would involve an admission to the hospital for one or more nights.
  Which hospital did you or your household member stay in overnight during that most recent stay?
  Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during the stay?
  Which of the following best describes how the decision was made to use that hospital?
  (Optional) Please write any comments that you would like to make: