4. Are there healthcare services in our region that you feel need to be improved and / or changed?
(Please be specific)
5. In your opinion, how much of a problem are the following causes of diseases or disability in
your community? (Check one box per row)
Not a Problem
Somewhat of a Problem
Major Problem
Don't Know
a) Cancer
?
?
?
?
b) Diabetes
?
?
?
?
c) Substance Abuse
?
?
?
?
d) Heart Disease
?
?
?
?
e) Sexual Transmitted Diseases
?
?
?
?
f) Mental Disorders
?
?
?
?
g) Obesity
?
?
?
?
h) Pneumonia / Flu
?
?
?
?
i) Respiratory Disease
?
?
?
?
j) Stroke
?
?
?
?
k) Suicide
?
?
?
?
l) Trauma
?
?
?
?
Other (please specify)
6. How well do you feel our local health care providers are doing in addressing the health needs
of the following age groups? (Check one box per row)
Very Good
Good
Fair
Poor
Very Poor
N/A
Infants
?
?
?
?
?
?
Age 1 - 12
?
?
?
?
?
?
Age 13 - 17
?
?
?
?
?
?
Age 18 - 44
?
?