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LGBTQ Community Health Survey
Required Required Question(s)
Thank you for your participation. This survey will be used to determine future health and wellness programming for the Inland Northwest LGBT Center.
 
Required 1.
I am a: (Choose all that apply)
Gay Male
Lesbian
Bisexual Male
Bisexual Female
Transgender M to F
Transgender F to M
Heterosexual Male
Heterosexual Female
Other 
Required 2.
What is your age?
 

  • 50 character(s) left.
Required 3.
What is your zip code?
 

  • 50 character(s) left.
Required 4.
How many people live in your household?
 

  • 50 character(s) left.
5.
What was your household income for 2007?
 

  • 50 character(s) left.
Required 6.
Have you had any of the following tests or screenings in the past year?
Pap smear
Mammogram
Human papillomavirus (HPV) test
Diabetes test
Body mass index screening
Prostate screening
High blood pressure screening
Colorectal cancer screening
Cholesterol screening
Sexually transmitted disease
Hep C screening
HIV/AIDS test
Required 7.
Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs or MSAs, or government plans such as Medicare?
Yes
No
Required 8.
Do you:
Smoke
Dip
Chew
No (if no skip to Question 10)
9.
How much do you smoke, dip or chew?
Occasionally or socially
Every day, but less than 10X
Every day, but more than 10X
Required 10.
Do you have one person you think of as your personal doctor or health care provider?
Yes
No
Required 11.
If you identify as LGBTQ, are you "out" to your health care provider?
Yes
No
Required 12.
Do you consider your health care provider to be "LGBTQ friendly"?
Yes, absolutely
Yes, sort of
Not really
Not at all
Don't know
13.
If you answered "Yes" to question 12 above, would you like to nominate him or her to be in the LGBTQ-friendly Health and Wellness Provider Directory on our Web site? (Providers will be contacted for their approval prior to listing in the directory.)
 

  • 500 character(s) left.
14.
Do you have any secondary health or wellness providers (such as massage therapists, chiropractors, mental health professionals, etc.) who you feel should be in the LGBTQ-Friendly Health and Wellness Provider Directory? (Providers will be contacted for their approval prior to listing in the directory.)
 

  • 500 character(s) left.
Thanks for your participation!