Community Health Assessment - Mount Sinai Medical Center

Email *

Zip *

Gender *

Female Male

Instruction:

Please answer the following questions which are recommended by the National Center for Chronic Disease Prevention and Health Promotion. Your answers will help Mount Sinai better address the needs of its community.

1. Health Care Coverage/Access *

Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

Yes No

2. Have you had an annual wellness or routine physical exam in the last two years? (not for a specific illness or injury) *

Yes No

3. Cardiovascular Disease/Heart Attack *

Has a health professional ever told you that you had angina or coronary heart disease?

Yes No

4. Cancer

Has a health professional ever told you that you have cancer?

Yes No

5. Men's Health

Have you ever had a Prostate-Specific Antigen (PSA) test?

Yes No None

6. Women's Health

Have you had a mammogram within the past two years?

Yes No None

7. Have you had a pap test within the past three years?

Yes No None

8. Diabetes *

Have you had a glucose / blood sugar test in the last two years?

Yes No

9. Has a health professional ever told you that you have diabetes? *

Yes No

10. Immunization *

Have you received a seasonal flu shot in the last year?

Yes No

11. Exercise/Physical Activity *

During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, golf, gardening, or walking for exercise?

Yes No

12. Sun Exposure *

Do you wear sunscreen with an SPF of 30 or higher, daily?

Yes No

13. Including you, how many family members are in your household? *

14. What is your age? *

15. What is your income? *

16. What is your ethnicity? *

17. What is your race? *

Community Health Assessment 2012