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Sweetwater-Nolan County Health Department ..... Health Disparities
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'PREVENTABLE DIFFERENCES IN THE OPPORTUNITIES TO ACHIEVE OPTIMAL HEALTH'
Your voice is important in linking the people to community resources and in a collaboration of sharing resources among community agencies.
Please answer to the best of your ability. Please DO NOT provide your name, phone number, or address.
Please put the month, day, and year upon taking this survey:
*
MM
/
DD
/
YYYY
What age group best describes you?
18-30
31-50
51-64
65 or older
Prefer not to answer
What gender do you most identify with?
Male
Female
Other
Prefer not to answer
Marital Status:
Married
Single/Never Married
Widow/Widower
Divorced
Domestic Partnership
Prefer not to answer
Please specify your ethnicity: (Please select all that apply)
African American
Asian
Caucasian
Latino or Hispanic
Not listed
Prefer not to answer
Language: (Please select all that apply)
English
Spanish
Not listed (Please list in the box below)
Prefer not to answer
Please list any languages you speak that are unavailable for selection from the above question.
Your answer
Education:
Some High School
High School Diploma
GED
Some College
Associates Degree
Bachelor's Degree or Higher
Technical/Trade
Other
Prefer not to answer
County of Residence:
Nolan County Resident
Non-Nolan County Resident
Type of Residence:
Own/Rent
Homeless
Housing Authority
Other
Prefer not to answer
Employment Status:
Full-Time
Part-Time
Unemployed
Disabled
Retired
Prefer not to answer
Household income:
Less than $25,000
$25,000-$50,000
$50,000-$100,000
$100,000 or higher
Prefer not to answer
Medical Insurance:
No medical insurance
Medicaid
Medicare
VA
Disability
Private insurance
Prefer not to answer
Do you have dental and vision insurance:
No dental and vision insurance
I have both dental and vision insurance
Dental only
Vision only
Prefer not to answer
Do you have any underlying or major health issues that you are unable to seek medical attention or care for?
Yes
No
Prefer not to answer
Do you have any disabilities that you are unable to seek medical attention or care for?
Yes
No
Prefer not to answer
Please specify any concerns you may have about your health conditions, disabilities, or mental health concerns that you may be experiencing (if you wish, please be as specific and detailed as possible):
Your answer
What are the main reasons you are UNABLE to obtain medical attention for basic care, emergency care, or for any physical or mental disability care treatment? (Please select all that apply)
No health insurance
Unable to afford private health insurance
Unable to afford co-payments and/or deductibles
Unable to afford prescribed medications or treatments
Communication Barrier (Limited to English speaking households)
Unreliable or no access for transportation
No internet access or available
Single or zero household caregiver
Physicians out of network or do not accept private/Medicaid/Medicare insurances
No primary care physician in the area in which you live
Inability to have access to physicians or referrals
Medical appointment waiting periods are too long
Unaware of the local hospital medical services
Fear
Untrusting of the health care system
I HAVE access to medical attention
Prefer not to answer
Other (Please specify below)
Please list any other reasons not provided on the previous question on the main reasons you are UNABLE to obtain medical attention for - basic care, emergency care, or for any physical or mental need/disability care and treatment:
Your answer
How has the COVID-19 Pandemic affected your life? (Please select all that apply)
Positive for COVID-19
Loss of employment due to COVID-19
Unexpected/extended days without pay due to COVID-19
Unable to seek medical care for COVID-19
Loss of a loved one due to COVID-19
Increase medical care due to COVID-19
Long term medical care due to COVID-19
Increased medical bills due to COVID-19
Experienced emotional distress, depression, anxiety, increased sadness, feelings of hopelessness
Unaffected by COVID-19
Never tested for COVID-19
Prefer not to answer
Other (Please specify below)
Please list any other reasons not provided on the previous question on how the COVID-19 Pandemic affected your life:
Your answer
Mental Health: Do you have local (Nolan County) access to emotional and mental health services through a counselor or therapist?
Yes
No
Unaware of resources available
Prefer not to answer
On a scale from 1-10, how important is your mental health to you? 1 being NOT very important, 10 being VERY important.
1
2
3
4
5
6
7
8
9
10
Clear selection
What do you think would help increase opportunities for support of any kind that would be help ease the effects and be beneficial to YOU if there happens to be a possible future pandemic or disaster?
Your answer
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