Congregational Health Assessment Form

Walking Towards Wellness : A Faith Based Wellness Initiative

Congregational Health Assessment
What is the Name of your Church?
What is your gender? *

Female Male
How old are you? *

Under 18 18 - 29 30 - 45 45 or more
Select all MEDICAL CONDITIONS that apply to you or immediate family. *

Acid Reflex Anemia Anxiety Asthma Back Pain Blurred Vision Cancer Constipation Depression Diabetes Diarrhea Diverticulitis Excessive Thirst Kidney Disease Knee Pain Insulin Resistance Frequent Urination Memory Loss Gout Heartburn Hernia Heart Failure Hypertension Hip Pain High Cholesterol Liver Disease Mental Health Sleep Apnea Stroke Not Applicable
How often do you visit on your PRIMARY CARE PROVIDER? (Doctor, Nurse Practitioner, Specialist) *

Quarterly Yearly Every 3-5 Years Not Often
Are you interested in improving your overall health this year? *

Yes No
Are there any prescription MEDICATIONS that you would like to get off of with improved nutrition and physical activity? *

No Yes
Would you like to learn how and what to EAT to live a healthier life? *

Yes No
Are you interested in GROWING your own food? (Herbs & Spices) *

No Yes
How PHYSICALLY ACTIVE do you consider yourself? *

Not Physically Active Moderately Physically Active Very Physically Active
How important is your MENTAL HEALTH to you? *

Not Very Important Important Very Important What is Mental Health?
What health related ACTIVITIES would you like to participate in within the newly formed Health & Wellness Ministry? *

Aerobics Boating Gardening Classes Health Walk Healthy Cooking Classes Health Seminars Hiking Line Dancing Marathons Runs Workshop

1 - No Improvement Needed

2 - Moderate Improvement Needed

3 - Significant Improvement Needed

My Nutrition & Dietary Practices

My Physical Fitness

My Medications

My Mental Health

My Weight

Name *

First Name Last Name
Email *
example@example.com
Cell Phone Number *

Area Code Phone Number
Will you be attending EBC's 1st Annual Nutrition, Health & Wellness Symposium on May 5, 2018? *

Yes, I will be attending. No, I will not be attending.
Are you interested in joining EBC's newly formed Health & Wellness Ministry *

Yes! Not at this time.
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Walking Towards Wellness : A Faith Based Wellness Initiative