Empowered for Health and Wellness - Survey
A collaboration between PowerHouse Church and Texas Southern University
Name
*
First Name
Last Name
Age Range
*
Please Select
18-25
26-35
36-45
46-55
56+
Gender
*
Male
Female
Zip Code
*
Ethnicity
*
Hispanic or Latino
NOT Hispanic nor Latino
Which health topics would you like to know more about? (Please select all that apply.)
*
Accessing Resources & Support
Alzheimer's/Dementia
Artificial Intelligence (AI), Technology, and Health Data
Breast Cancer
Chronic Kidney Disease
Clinical Research
Colon Cancer
Diabetes
Nutrition, & Weight Management
Healthy Aging
Heart Disease & Stroke
High Blood Pressure
Immunizations
Lung Cancer
Maternal & Child Health
Medication Interaction
Mental Health
Navigating the Healthcare System
Prostate Cancer
Respiratory Disease (Asthma and COPD)
Other
Which resources would help you? (Please select all that apply.)
*
Resources to navigate the healthcare system.
Resources for financial literacy.
None
Other
Would you like to be added to our mailing list?
*
Yes
No
If you selected "yes" to the previous question, please provide your e-mail.
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