Basic Health Survey

To effectively plan for the Health and Wellness ministry at our church, your input is very important! Please take a few moments to complete this health survey. All information is confidential and will be used only for planning health programs for your benefit.

What is your age?

What are your children's ages?

My Marital Status Is:

I can attend health programs and events on the following days of the week:*

The best time for me to attend health programs and events would be:*

MorningsAfternoonEvening

I'm interested in learning more about:

I'd like more information about the following Adult issues:

Women's Health IssuesMen's Health IssuesYour Medicine Cabinet

I'd like to learn more about these health topics:

I struggle with or have been diagnosed with the following health conditions:

I'd like more information about the following common TEEN health issues:

Eating DisordersDepression/SuicideConflict/CommunicationPeer Pressure

Email

Please enter the word in the box for security*

In addition to the items already checked above, what would you like more info. about?

Thank you for your cooperation. God Bless You!