The mission of our CHNA is to reach out in God’s love to promote health and wellness of body, mind and spirit in our church family and community. Please take a minute or two to fill out this questionnaire. It will help us to plan health programs and activities that are of interest to you and your family. This is an anonymous survey and all responses will remain confidential. If you wish to speak to our one of health ministry team contact information is provided at the end of this survey.
Church Name
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Please check the top five concerns that you have about your physical health from the list below. Please check only five.
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Abuse/ Violence/ Bullying
Affording Health Care
Alcoholism
Anxiety/Fears
Arthritis
Cancer
Caregiver Stress
Dementia/Alheimer's/ Memory
Depression
Developmental Disabilities
Diabetes
End of life decisions
Financial Planning
Grief/Loss
Headaches
Heart Disease
Healthy Relationships
High Blood Pressure
HIV/AIDS
Lack of Exercise
Living with a Chronic Disease
Lung Disease
Medications- Understanding
Menopause
Mental Health
Nutrition
Parenting
Pediatric Concerns
Physical Disability
Senior Housing Placement
Sexual Identity
Sexual Issues
Sexually Transmitted Infections
Sleep Problems
Smoking
Stress
Substance Abuse
Transportation to Appointments
Weight control/ Obesity
No Response
Other
Please list the top three spiritual concerns/beliefs that have impacted your physical health.
Example: answer 1. "Ability to let go or accept" (my diagnosis or my divorce because it causes me stress)
Ability to let got or accept
blanks
Hope/Meaning diminished because of
blank
Grief/Loss due to
Anger about/towards
Emotional healing due to
Lack of trust due to
Death or impeding death of
God/Bible doubt due to
Prayer-lack of/ concerns about
Faith challenged because of
Forgiveness of self/other
Loneliness/Isolation because of
Trauma-past/current related to
Church/community-lack of due to
Relationship concerns: Marriage/Partner/DIvorce/Seperation/Singleness
Other
Please identify any of the following conditions below that have affected your health
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Lack of access to medical care
Little or no insurance coverage
Employment conditions-unsafe, toxic, etc.
Lack of access to safe and affordable housing
Unsafe neighborhood/green space
Lack of education
Lack of Employment
Little acess to fresh fruits and vegetables
Unsafe/unhealthy living conditions
Ability to read and understand medical/health information
Economic, money concerns
Lack of transportation
No response
Other
Please rate your overall health from 0-10, where 0 means poor and 10 means excellent. N/A for no answer
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How many servings of fruits and vegtables do you eat each day?
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0
1-3
4-6
7 or more
No response
Have your had your blood pressure taken within the last year?
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Yes
No
No response
If yes, my blood pressure is:
Normal
Higher than normal
Don't know
No response
Approximately, how many hours a week do you engage in at least moderate intensity physical activity ( for example, a brisk walk)?
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None
at least 30 minutes
1 hour
1.5 hours
2 hours
2.5 hours or more
No response
Submit
Should be Empty: