HEALTH FEEDBACK FORM

Please complete the form below to share your health feedback as a Spartanburg County resident.

Zip Code:

Date of Birth:

Ethnicity:

Race:

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native American or Other Pacific Islander

White

Other

Do you have health insurance that helps pay when you see the doctor?

If your answer is no to the previous question, please share why:

Do you have health problems that don't go away, such as asthma or diabetes?

If your answer is yes to the previous question, how do they affect your everyday life?

Is it easy to find someone to talk to when you feel sad or worried?

Do you think the help you get for the previous question is good enough?

Do you have safe places to play and exercise close to your home?

It is easy for you to get to a doctor or hospital from where you live?

Are there things around your home, such as dirty air or not enough parks, that you think make it harder to be healthy?

Do you think every person in your neighborhood has the same chance to be healthy?

If your answer is no to the previous question, what makes it hard to be healthy?

In your own words, how do things such as your home, your school, or your family's jobs impact how healthy you are?

Free Text

Optional

Please complete if you want to be contacted.

Name:

Phone Number:

Email Address:

Please check the below box if you would like a Community Health Equity staff member to contact you.

Yes, I would like to be contacted.

(For CRCs & CHRCs only) Referred by: