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
*
Rows
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.
Submit
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