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 *
Required
If you have any health insurance coverage at all, do you understand how to use it? *
When was your last doctor’s visit? *
Where do you go for healthcare? *
Have you had any of the following preventive procedures in the past year? Check all that apply: *
Required
Are you able to visit a doctor when you need to?
Clear selection
Please identify any barriers that keep you from having a doctor’s appointment. Check all that apply: *
Required
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. *
Required
Are you a grandparent raising a grandchild? *
If YES, would you be interested in resources, groups, or information about grandparents raising grandchildren?
Clear selection
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? *
What is your zip code? *
What is your gender? *
What is your age? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Mountain Laurel Medical Center.