Thank you for taking a few minutes to help the Calvert County Community Health Roundtable assess health needs in Calvert County.  The results will be used to plan future health services.  All of your answers are completely confidential and you cannot be identified in any way.

1	What is the zip code where you live:
	20610		20629		20657		20678		20688		20714		20736		20758
	20615		20639		20676		20685		20689		20732		20754		Other

2

Your Age:

18-34

35-49

50-64

65 and over

3

Your Gender:

Male

Female

4	Your Race/Ethnicity:
	Caucasian, Non-Hispanic	Asian/Pacific Islander	American Indian/Alaska Native
	African American, Non-Hispanic	Hispanic	Other

5

How long have you lived in Calvert County?

Less than 1 year

1-4 years

5-10 years

10+ years

6

Do you have health insurance?

Yes

No

7	If you do not have health insurance, what is the main reason why?
	Employer does not offer insurance		Insurance refused coverage		Can't afford to pay premium
	Work part-time, not eligible		Decided voluntarily not to purchase		Lost medical assistance eligibility

8

Was there a time during the last 12 months when you tried to get an appointment with a doctor in Calvert County, but could not get the appointment when you needed it?

Yes

No

9	If you answered YES to the question above, what was the main reason you could not get an appointment when you needed one?
	I was not insured	Type of doctor needed not available in area
	Doctor did not take my insurance	No transportation
	Office hours were not convenient	Copay was more than I could afford
	Too long of a wait for the appointment

10

In the last 12 months, have you had to go outside Calvert County to get medical care because the care you needed was not available in Calvert County?

Yes

No

11	For what specific type of medical care did you have to go outside the county?

12	Have you ever been told by a doctor or other health professional that you have any of the conditions listed below?  (Check all that apply)
	Stroke	Diabetes	High cholesterol	Lyme disease
	Asthma	Arthritis	Congestive heart failure	Hepatitis C
	Coronary heart disease	High blood pressure	Depression	Lung disease

13	Have you ever been told by a doctor or other health professional that you need to lose weight?
	No, never been told	Yes, lose 10-20 lbs	Yes, lose 21-50 lbs	Yes, lose 51-100 lbs	Yes, lose 100+ lbs

14	How many days per week do you take part in at least 30 minutes of any physical activity?
	0	1-2	3-5	6-7

15

Do you now or have you ever smoked cigarettes?

Never smoked

Currently smoke

Used to smoke

Trying to stop

16	If you have quit, how long has it been since you last smoked a cigarette?
	Less than 3 months	3 months - 1 year	1 - 5 years	5+ years

17	How serious a problem do you think underage drinking of alcohol is in Calvert County?
	Very serious	Somewhat serious	Not very serious	Not serious at all	Don't know

18	Are you concerned that a family member has an addiction?
	No	Yes, prescription medications	Yes, illegal drugs	Yes, alcohol	Yes, other

19	Are you currently caring for an elderly Calvert County resident either in your home or in that person's home?
	Yes	No

20	Do you currently have an unfilled need for any of the following services for the person you are caring for:  (Check all that apply)
	Adult day care	Senior independent living	Assisted living	Skilled nursing home

21	Do you currenlty have an unfilled need for any of the following services for yourself:  (Check all that apply)
	Adult day care	Senior independent living	Assisted living	Skilled nursing home

22	What kinds of help do you think you might need to remain in your home within the next 5/10 years because of aging or health issues?
	Personal care & companionship	Meals	Chore service	I don't anticipate needing help
	Home adaptations	Transportation	Financial assistance

23	When was the last time you or a family member used Calvert Memorial Hospital in Prince Frederick for healthcare services?
	less than 6 months	1-5 years ago	Never used Calvert Memorial  Hospital
	6 months-1 year ago	More than 5 years ago

24	Which, if any, of the following did you or your family members use (Check all that apply)
	Inpatient (overnight)	Outpatient (Not overnight)	Emergency Department	Never used services

25	The following questions refer to your perception of Calvert Memorial Hospital in Prince Frederick.  Based upon what you know about the hospital, please rate the following:
		Excellent		Very Good		Average		Below Average		Poor		Don't Know
	Quality of nursing care..
	Quality of medical staff (doctors)
	Helpfulness of the staff
	Sophistication of technology
	Quality of care in the Emergency Department

26	Compared to 5 years ago, how would you rate the overall reputation of Calvert Memorial Hospital?  Would you say it is:
	A lot better	Somewhat better	About the same	Worse	Much worse	Don't know

27	Please rank the following items in terms of what is most important to you when it comes to choosing a hospital:
		Most Important		Very Important		Important		Somewhat Important		Least Important
	Reputation for quality of care...
	Availability of latest technology
	Friendly and courteous staff
	Facilities are modern and up-to-date
	Has a wide variety of medical specialties available
	Reputation of physicians

28	Based on your answers above, how would you rate Calvert Memorial Hospital?
	Excellent	Very good	Average	Below average	Poor	Don't know

29	How do you typically get information about Calvert Memorial Hospital?  (Check all that apply)
	Newspaper	Direct mail	Advertising	Never gotten information about the hospital
	CMH website	My doctor	Other people