Health Access Survey Please complete all fields. Zip Code: Age: Gender: Please Select...MaleFemale Race: Please Select...CaucasianAfrican AmericanAsianAmerican Indian or Alaska NativePacific Islander or Native HawaiianOther (Specify) -->    Ethnicity: Hispanic/Chianco/Latino: Please Select...YesNo Primary Language Spoken: Please Select...EnglishSpanishOther (Specify) -->    Other Language Spoken: Please Select...NoneEnglishSpanishOther (Specify) -->    How would you rate your Health?: Please Select...Very GoodGoodfairPoorVery Poor If your community had a sliding fee (based on your income) clinic, would you use it?: Please Select...YesNo Have you ever had a problem getting a doctor's appointment because you could not pay: Please Select...YesNo When you call the doctor’s office, how long do you have to wait to get an appointment?: Please Select...1 Day2 Days3 Days4 DaysMore than 4 Days If you have an appointment, how long after your appointment time does the doctor see you?: Please Select...15 to 30 minutes30 minutes to 1 hour1 to 2 hoursMore than 2 hours When you don't have an appointment (walk-in), how long does it take before the doctor sees you?: Please Select...30 minutes to 1 hour1 to 2 hoursMore than 2 hoursMy doctor does not take walk-in's How many times have you, or members of your family visited the emergency room in the last year? : What other services do you need to help you with your health needs? (check all that apply) Counseling Services Psychiatrist Help in applying for benifits (DHS) Social Services Health Classes Senior Citizen's Day Program Women's Doctor Parenting Classes Drop-in Day Care Eye Doctor Psysical Therapy Alcohol/Drug Counseling Cancer Treatment Diabetic Care Dentist Family Doctor Children's Doctor Someone to help you find and get the medical and/or social services you need to feel better Special Doctor: