Pacific Northwest Business Consultants


1.	In what area do you reside?	Jackson County Josephine County Douglas County None of the Above	Coos County Lane County
2.	Gender?	Male Female
3.	Are you an enrolled Member from an American Indian or Alaska Native Federally Recognized Tribe?	Yes No Descendant

4.	What age bracket are you in?
5.	How many children do you have?

6.	Do you see a dentist regularly for cleanings and check ups?	Yes No


7.	What barriers make it difficult for you or your household members to get access to Medical/Dental care? (check all that apply)	Distance to and from services Lack of transportation Other (specify)	Expense Getting an appointment
8.	Do you use or need prescription medication to control pain?	No Daily Weekly Monthly
9.	Are you currently using prescribed medication for any of the following health conditions? (check all that apply)	Pain Liver Disease AIDS Tuberculosis Diabetes Kidney Disease	High Blood Pressure Tobacco Addiction Heart Problems Respiratory Problems Cancer Osteoprosis (Brittle Bones)
10.	If Cow Creek Health & Wellness Center had a medical clinic in Canyonville (near Seven Feathers), would you use the medical clinic?	Yes No
11.	If Cow Creek Health & Wellness Center had a dental clinic in Canyonville, what type of service provider do you feel would be best for you and your family? (check all that apply)	Dentist Orthodontist (braces) Pedodontist (children's dentist) Oral Surgeon
12.	If anyone in your household were to seek out individual or group counseling or therapy, which of the following would you or they most likely attend? (check all that apply)	Anger Management Parenting Skills Anxiety Panic Attacks Adult Children of Alcoholics Children of Domestic Violence	Grief/Loss Marital Counseling Adults Molested as Children Child/Adolescent Problems Drug & Alcohol Counseling
13.	Would any of the following social services be beneficial to you? (mark all that apply)	Substance Abuse Counseling Tribal Child Protection Services Child Day Care Program Delinquency Services for Children	Tribal Transportation Child & Spousal Abuse Counseling Marriage Counseling Family Violence Counseling
14.	Are there any people in your household that currently have a controlled substance (drugs) or alcohol abuse problem?

15.	How many people live in your household?