Health Resource Capacity Assessment for Putnam, Connecticut, May 2001

Parent Survey

We need your help. We are conducting a study of the health of Putnam residents and, as the parent or guardian of a child in the Putnam schools, we'd like to ask you a few questions. Your answers will be kept completely confidential. If you'd like a copy of the final report, please check here

If you have any questions about the study or this questionnaire, call us at the Northeast District Department of Health 774-7350 and ask for Laura Sasser. When you are finished, please have your child return the survey to his/her teacher.

Name:

Address:

What is your age? How many children do you have?

What are their ages?

Are there other adults living in your home?

1. Yes
2. No
3. How many?

Who do you ask if you have a question about your family's health? Circle all that apply

1. a friend or family member
2. my doctor or health care provider
3. search the internet
4. call the hospital or a clinic
5. no one
6. other

When was the last time you saw a doctor for a check up for yourself?

Where did you go for the check up?

How long did you have to wait for an appointment? Circle one

1. less than a month
2. one or two months
3. three or four months
4. five or six months
5. more than six months

When was the last time one of your children saw a doctor for a check up?

Where did you take them for the check up?

How long did you wait for an appointment? Circle one

1. less than a month
2. one or two months
3. three or four months
4. five or six months
5. more than six months

When was the last time someone in your family had a medical emergency? Was it:

1. You
2. Your child
3. Another family member

Where did you/they go?

How did you/they get there?

Did you/they get the care you needed? Circle one

1. We got excellent care as quickly as we needed it
2. We got good care, quickly
3. We got what we needed in time
4. We got care, but we had to wait or it wasn't great
5. We didn't get what we needed or it was late

Do you or any members of your family have on-going health problems? Circle all that apply.

1. No
2. Yes, high blood pressure or heart problems
3. Yes, diabetes
4. Yes, asthma
5. Yes, depression or mental illness
6. Yes, substance abuse
7. Yes, disability
8. Yes, other

Use the scale below to assess how available regular, preventive health care is for you and your family, Circle one

1. Shortage
2. Some problems
3. Adequate
4. Good
5. Surplus

Are there some people in Putnam who have trouble getting health care?

• Yes
• No

Who? Why?

Do you have health insurance for yourself?

• Yes
• No

Do your children have health coverage?

• Yes
• No

If yes, is it through: Circle one

1. an employer
2. The state/HUSKY
3. self-pay

Is the cost of health care a problem for you or your family?

• Yes
• No

Have you ever limited health care for yourself or your family due to cost, for example delayed seeing a doctor or not filled a prescription?

• Yes
• No

Is there a gun in your home?

• Yes
• No

If so, are there trigger locks on the gun(s)?

• Yes
• No

Is it locked separately from the ammunition?

• Yes
• No

Does anyone in your home smoke?

• Yes
• No

Do you and your family regularly wear seat belts in the car?

• Yes
• No

Do you exercise regularly?

• Yes
• No

How do you rate your health? Circle one

1. Excellent
2. Very good
3. Good
4. Fair
5. Poor

How do you rate the health of your family overall? Circle one

1. Excellent
2. Very good
3. Good
4. Fair
5. Poor

What health needs do you see for people in Putnam? What could be done to make people healthier?

Please answer the questions below for you and your child. Place a check (v) on each line that applies.

1. How long has it been since you last visited the dentist or a dental clinic?

2. What are the most important reasons that you have not visited the dentist in the last year?

3. Do you have dental insurance coverage that pays for some or all of your routine dental care?

4. Are you eligible for State Assistance (Medicaid, HUSKY A, HUSKY B) but cannot find a dentist to care for you?

5. In the past two years, how many days total have severe dental problems prevented you from engaging in your daily activities such as work or school? (include dentist visits for emergency or non-routine treatment)

6. If a local dental health center were available in your community, would you be interested in receiving dental care there?