Bridget Gainer, 10th District Cook County Commissioner
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Cook County Health Needs Survey

Sponsored by Cook County Commissioner Bridget Gainer.

This questionaire was drafted with the assistance of University of Chicago Medical Center, Cook County Health and Hospitals, and Erie Family Health Center.

1.) How would you rate your own personal health?
2.) What is your health insurance status:
3.) If insured, what type of coverage do you have?
4.) Your last visit to the doctor was:
5.) Where do you usually go for health care?

       (which: )
       (which hospital: )

       (which: )

       (where: )		  
6.) When needed, how easy is it for you to see a doctor?
7.) If you answered moderate or difficult to the last question, why?
8.) On last visit, how long did it take to get an appointment to see a doctor?
9.) In the last year, has cost prevented you from getting a needed prescription?
10.) Have you ever used the Cook County Stroger Hosipital?
11.) If so, was your experience
12.) Do you travel out or your neighborhood to receive health care?
13.) If yes to question 12, where do you go and why?
14.) In the following list, what are the 5 most serious barriers to you receiving health care?
15.) When was the last time you visited a dentist or received dental care?
16.) Have you needed mental health care in the last two years?
17.) If you needed mental health care, where did you go?
18.) Are you currently employed?
19.) If you are currently employed, which describes your current status?
20.) Were you not able to work or perform your daily activities because of illness in the last 30 days?
21.) If you're not working, is it because of your illness or an untreated disability?
22.) Annual household income: