Page Free Clinic QuestionnaireHelp the Page Free Clinic evaluate services and improve health delivery patterns in the community.Page Free Clinic Eligibility:Resident of Page CountyAge is 19-64Yearly income before taxes is between $0-300% of the Federal Poverty LevelDo not have, or qualify for, any type of medical insurance, including Medicaid and Medicare Page Free Clinic 250 Memorial Drive, Suite C, Luray, VA 22835 • 540-743-1054 Open Every Tuesday 4-7pm 1. Do you know there is a free clinic in Page County? * Yes No 2. Do you know the clinic has doctors on staff that provide free medical care to uninsured residents of Page County: (check the care you are interested in and that the clinic currently provides) * check-up screenings and basic lab work prescription services diabetes support dental referrals for free care women’s health services fitness memberships HIV testing 3. Are there other care needs you have that are not listed above? * 4. Why don’t you use the Page Free Clinic? * I am not familiar with the Free Clinic services I am not eligible for Free Clinic services I don’t know where the clinic is located I can’t make it during the hours the clinic is open (every Tuesday from 4-7pm) I don't need free services, I have insurance 5. If you have insurance, what type of insurance do you have? * Medicaid Medicare COBRA Marketplace Private Insurance ((BlueCross BlueShield, Anthem, Kaiser, etc) 6. How often see a doctor or specialist? * Never Once a year for a check-up Only when I feel bad 7. When you are feeling bad, what do you do? * Ignore It Go to the internet for possible causes and treatments Try to manage myself Call a doctor Go to the Emergency Room 8. If you need medical care, where do you typically go first? Urgent Care out of town Primary Care Provider Free clinic Emergency Room Out of county doctor 9. Do you have a care team you prefer? * Valley Health Multi Specialty Clinic Page Memorial Hospital Winchester Medical Center Sentara in Harrisonburg Page Free Clinic Other 10. How easy is it for you to receive the medical care you need? * I can access medical care with no problem I sometimes struggle with accessing medical care I often struggle to access medical care Accessing medical care is very difficult for me 11. Why don’t you seek medical care? * Doctor office closed when care is needed The care I need is not in my area Waitlists for appointments are too long There are not enough providers/doctors I don’t care for the providers/doctors I can’t drive I have a hard time understanding the paperwork I don’t have the time I can’t get off work I have a language barrier I can’t afford additional costs (either with or without health insurance) I seek care - no problems 12. At your job, how often do you call out sick? Never Two times per year Every week Every month Unemployed 13. What is your income range per household (per year)? * $0-$10,000 $10,000-$20,000 $20,000-$40,000 $40,000-$60,000 $60,000-$80,000 $80,000-$100,000 $100,000+ I'd rather not answer 14. Where do you live? * Shenandoah Luray Stanley Rileyville 15. What is your age range? * 18-25 25-40 40-55 55-70 70 and older Thank you!
