Wellness Made Easy

Wellness Made Easy

Shorten Community Survey

Please answer as many questions as you feel comfortable with, as this information helps us help you.

    1. When you are sick, where do you most often go to get help?
    My primary care doctorAn urgent Care CenterEmergency Room at the hospital

    2. How do you most often get to doctor appointments? Please choose one.
    My own carThe public busesI walkI ride a bikeI use a taxiA friend or family member takes meI don't have transportation, so it is very difficult to get to appointments

    3. Do you have any of the following types of health insurance?
    Private medical insuranceMedicareMedicaidVA benefitsNone

    4. Of the list below, which one of these is the most important to you? CHOOSE ONLY ONE PLEASE
    Increasing my incomeImproving my housingFinding healthcare when I need itStaying healthy so that I don't need healthcareBeing able to afford enough food for myself and/or my family

    5. In the past 3 months, have you had trouble paying for any of the following? Select ALL that apply.
    NoFoodHousing (rent/mortgage)Utilities (electricity/heat or air condition)Medical ExpensesMedicationsChildcareOther:

    6. What county do you live in?
    DorchesterWicomicoWorcesterSomersetOther:

    7. What is your age?
    Under 1818-34 years old35-54 years old55-75 years old76 and olderPrefer not to say

    8. What is your gender?
    MaleFemale35-54 years oldPrefer not to sayOther:

    9. What is your ethnicity?
    WhiteHispanic or LatinoBlack or African AmericanNative American or American IndianAsian/Pacific IslanderPrefer not to sayOther:

    10. What is your current employment status?
    EmployedUnemployedStudentRetiredSelf-EmployedUnable to WorkPrefer not to say

    Thank you for completing this survey, your feedback is important!

    Name:

    Phone Number

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