Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.The zip code of my residence is:What is your current age: or all the 1. Has your household used the services of a hospital in the past 24 months?Yes (Go to Q2)No (Skip to Q7)Don’t know (Skip to Q7)2. At which hospital(s) were services received? (Please check/list all that apply)Fairview Regional Medical Center (Skip to Q4)Other (please specify Hospital and City, then go to Q3)List other hospital(s) from question 2 if you answered other.3. If you responded in Q2 that your household received care at a hospital other than Fairview Regional Medical Center, why 3. did you or your family member choose that hospital? (Please answer then skip to Q6) (copy)Physician referralQuality of care/Lack of confidenceCloser, more convenient locationAvailability of specialty careInsurance reasonsOther (Please list below)Answer (copy)4. If you responded in Q2 that your household received care at Fairview Regional Medical Center, what hospital service(s) were used?Diagnostic imaging (X-ray, MRI, CT, Ultrasound)Hospital InpatientLaboratorySkilled nursing (swing bed)Outpatient infusion/ShotsEmergency room (ER)Physician servicesRespiratory Therapy/Pulmonary Function TestPhysical, speech, or occupational therapyOther (Please list below)Answer5. How satisfied was your household with the services you received at Fairview Regional Medical Center?SatisfiedDissatisfiedDon’t know6. Has your household been to a specialist in the past 24 months?YesNo (Skip to Q10)Don’t know (Skip to Q10) 7. What type of specialist has your household been to in the past 24 months and in which city were they located? Type of SpecialistCitySingle Line TextSingle Line TextSingle Line Text (copy)Single Line Text (copy)Single Line Text (copy) (copy)Single Line Text (copy) (copy) Add Remove 8. Did the specialist request further testing, laboratory work and/or x-rays?YesNoDon’t know (Skip to Q10)9. If yes, in which city were the tests or laboratory work performed?10. What kind of medical provider do you use for routine care (Please select all that apply) ?Primary Care physicianMid-Level Clinic (Nurse Practitioner or PA)Tribal Health CenterEmergency Room/HospitalIncome Based Health CenterSpecialistUrgent care/Walk in clinicHealth DepartmentOther (Please list below)Answer (copy)11. Has your household been to a primary care (family) doctor in the Fairview area?Yes (Go to Q12)No (Skip to Q13)Don’t know (Skip to Q13)12. How satisfied was your household with the quality of care received in the Fairview area?SatisfiedDissatisfiedDon’t know13. Do you think there are enough primary care (family) doctors practicing in the Fairview area?YesNoDon’t know14. Are you able to get an appointment, within 48 hours, with your primary care (family) doctor when you need one?YesNoDon’t know15. Have you used the services of a walk-in, urgent care or after hours clinic in the past 24 months?YesNoDon’t know16. Would you utilize a walk in and/or after hours clinic if offered in Fairview?YesNoDon’t know17. What concerns you most about health in the Fairview area (Please select all that apply) ?Heart diseaseSubstance abuseCancersObesityDiabetesAccessing primary careDentalAccessing specialty servicesTeen PregnancyMotor vehicle crashesSuicideMental healthOther (Please list below)Answer (copy) (copy)18. What additional health and wellness services would you like to see offered in the Fairview area?19. Has your household used telemedicine services, a visit either by telephone or video with your provider, in the past year?YesNo (Skip to Q21)Don’t know (Skip to Q21)20. How satisfied was your household with the quality of care received via telemedicine?SatisfiedDissatisfiedDon’t know21. How would you prefer to be notified of community events? (Please select all that apply)NewspaperEmailSocial MediaRadioWebsiteSubmit
