School Based Health Center Spring 2019 Anonymous Survey
The purpose of this survey is to determine how prepared our patients are to transition away from the School Based Health Center. Our goal is to create a specific transition plan to help make this an easy adjustment. This survey is competely anonymous. No identifying information will be collected
What is your grade level?
What is your age?
What is your gender?
1. Have you been seen by the school based heath center?
2. If you have been seen at the school based health center, what percentage of your health care was provided there?
Less than 25%
More than 75%
3. Do you have a doctor for you family? (If no skip to question #7)
4. Have you seen you doctor in the past 12 months
I don't have a doctor
5. Do you know how to make an appointment with your doctor
Yes, I have their phone number and call for an appointment
Yes, I have their website and schedule an appointment online
Yes, they accept walk-in appointments reguarly
No, I don't have a doctor
No, I don't know how to reach my doctor
6. Do you know how you will get to you appointments with you doctor?
Yes, I will drive myself
Yes, I will walk myself
Yes, I will take public transportation
Yes, I will have a reliable friend or family member take me
No, I do not have a consistent and reliable way of making it to my appointments
No, I do not have a doctor
7. Do you have any chronic/long term/repeat medical concerns that require follow-up? (If no skip to #9)
8. Do you have a specialist doctor who treats these concerns?
9. If you are sick where do you go for treatment? (Check all that apply)
School Based Health Center
Medical Clinic at Walgreens, Target or CVS
10. Do you take any medication on a regular basis? (If you answer no, skip to question #13)
11. Do you know the name, dose and instructions for your medications?
12. Do you use the same pharmacy for all prescriptions?
Yes, I use 1 pharmacy
No, I use more than 1 pharmacy routinely
No, I don't have a "home" pharmacy, I use many
13. Do you have insurance?
I don't have any insurance
I have insurance, but I don't know what insurance plan I have
I don't know
I have insurance and know what it is (Please list it below in the "Other" category
14. Do you have fruits and vegetables at home?
15. Do you know where you will be living after you leave high school?
Yes, at college
Yes, at home
16. Have you ever seen a therapist/counselor/or social worker for counseling? (If you answer no, skip to question #19)
17. Where have you seen a counselor/therapist or social worker?
Student Services Department at Maine East
School Based Health Center
Private therapist through health insurance
18. If being seen at Student Services or the School Based Health Center, do you have plans to establish care with a counselor/therapist/social worker after graduation? (If no, skip to question #23)
19 Do you know how to find another counselor/therapist/social worker?
20. Have you met with your counselor/therapist/social worker over the last 12 months?
21. If needed, would you know how to make an appointment with a counselor/therapist/social worker?
22. Would you have transportation if you had an appointment with a counselor/therapist/social worker?
23. If you were struggling with a stressful life situation (depression, anxiety, or any other issues affecting your life) where would you reach out for help?
My existing therapist
My school counselor
The counseling center at my university/college
Community counseling center
Look for a therapist through my medical insurance
Ask a parent or friend for help with finding a therapist
24. Do you have any additional concerns regarding your healthcare that need to be addressed once you leave the School Based Health Center?
Yes (If yes, please enter in the "other" box what those concerns would be)
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