Community Needs Assessment Survey
Mountain Laurel Medical Center is collecting information to find out what health needs are important in our community. Thank you for helping us by answering the questions below!
****You do not need to be a Mountain Laurel Medical Center patient to complete the survey.***
Types of insurance coverage you currently have
Don’t have insurance
If you have any health insurance coverage at all, do you understand how to use it?
When was your last doctor’s visit?
Within the last 12 months
Within the last 2 years
Within the last 5 years
Over 5 years
Have never had a routine doctor’s visit
Where do you go for healthcare?
Urgent Care Clinic
I do not receive routine healthcare
Have you had any of the following preventive procedures in the past year? Check all that apply:
Mammogram (females only)
Pap smear (females only)
Colonoscopy or occult blood test for colon cancer
Blood Pressure Check
Skin Cancer Screening
Prostate screening (males only)
Cardiovascular/heart disease screening
Bone density test
None of the above
Are you able to visit a doctor when you need to?
Please identify any barriers that keep you from having a doctor’s appointment. Check all that apply:
No appointment available
Cannot afford it
Cannot take time off from work
No specialist in my community for my condition
I don’t understand what my doctor is telling me
I do not have any barriers
If you have a medical condition, are you interested in services to better manage your condition?
If NO, why?
Please select the top 3 health challenges you face.
High blood pressure
Joint pain or back pain
Mental health issues
I do not have any health challenges
Are you a grandparent raising a grandchild?
If YES, would you be interested in resources, groups, or information about grandparents raising grandchildren?
Do you feel your community has to resources to take care of your health care needs?
If NO, please list the resources you would like to see in the community:
What is your highest level of education?
Less than High School
High School Graduate/GED
Post Graduate Degree
What is your zip code?
What is your gender?
Prefer not to say
What is your age?
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