GLBT Health Survey
confidential, anonymous, informational, no data is collected about you at all!

1. GLBT Health Awareness Week

1. For each aspect of your local GLBT Health Awareness Week Events, please tell us how much you agree or disagree with the statements.

I Totally AGREE

I Agree Somewhat

I Neither Agree nor Disagree

I Disagree Somewhat

I Totally DISAGREE

N/A

I was totally unaware of this campaign

I saw info about it, but did not attend any events or look into if further

I found useful information and resources

This is an important campaign

2. Your Health Care

Tell us about your health care?

I Totally AGREE

I Agree Somewhat

I Neither Agree nor Disagree

I Disagree Somewhat

I Totally DISAGREE

N/A

My provider is very sensitive to GLBT issues.

My provider asks about my sexual activates and cares about my sexual health.

I get a rectal / cervical screening at least once a year

I get Sexually Transmitted Disease Screenings at least once every six months

Not sexually active / or have very safe sex

I think it is important for sexually active people to get tested for HIV at least once every six months.

3. Overall Satisfaction

Overall, how satisfied are you with your health care?

Very Satisfied	Somewhat Satisfied	Neither Satisfied nor Dissatisfied	Somewhat Dissatisfied	Very Dissatisfied

4. Self Description

I would consider myself as:

Female	Female to Male	Male to Female	Male	Androgynous

How would you describe your Sexual Orientation?

Lesbian	Bisexual	Gay	Heterosexual	Undecided

5. Barriers

My Health Care Provider is

Female	Female to Male	Male to Female	Male	Androgynous	I do not have a health care provider

How would you describe your Health Care Provider's Sexual Orientation?

Lesbian	Bisexual	Gay	Heterosexual	Undecided/ Don't Know	I do not have a health care provider

How comfortable to you feel talking about these issues to your health care provider?

Very	Somewhat	Reluctant	Very Little	Not at All	I do not have a health care provider

Check ALL barriers that apply to you:

No LGBT Providers in my local region
Lack of Insurance
Lack of ability to pay for health care
Lack of Trust of health care delivery
Previous bad experiences with care

Too much stigma and discrimination in my community
Denied Health care because of gender Identification
Lack of Transportation
Lack of stable housing
Fear of being tracked and privacy violations

6. Suggestions

What Suggestions would you make to improve health care for GLBT persons in your area?:

Thank you. Your health and feedback are important to us.

GLBT Health Survey confidential, anonymous, informational, no data is collected about you at all!

GLBT Health Survey
confidential, anonymous, informational, no data is collected about you at all!