Concord Christian Church Survey
Required Required Question(s)
PURPOSE:

In order to assist the Health & Wellness Ministry in planning programs and activities that will meet the healthcare interests and needs of everyone at Concord Christian Church, we would like your input by asking you to answer the following questions.

 
 
PERSONAL INFORMATION:
 
Required 1.
Age:
under 20
21-29
30-39
40-49
50-59
60-69
70-79
80 and up
Required 2.
Gender:
Female
Male
Required 3.
Race:
White
Black
Hispanic
Asian
Other  
Required 4.
Marital Status:
Single
Married
Divorced
Widowed
Required 5.
Employment Status:
Employed
Unemployed
Retired
Homemaker
Required 6.
Health Insurance:
Yes
No
Required 7.
Primary Care Physician:
Yes
No
HEALTH INFORMATION:
 
8.
Please check if you currently have, or have a history of any of the following conditions:
Heart Disease
High Cholesterol
Cancer
Depression
Diabetes
Weight Problems
Lung Disease
Mental Problems
High Blood Pressure
Arthritis
Osteoporosis
Physical Disability
Other  
HEALTH PROGRAMS/ACTIVITIES:
 
9.
The following is a list of various programs and activities that could be offered through the Health & Wellness Ministry.  Please check all that you would participate in, if offered.
CPR Course
Healthy Eating
Women's Health/Men's Health
Medications
Caregiver Role
Adolescent Health
Depression
Stress Reduction
Weight Loss
Cancer Recognition
Death & Dying
Infant/Child Health
Substance Abuse
Exercise/Fitness
Smoking Cessation
Screenings (BP, Cholesterol)
Living Wills/Advanced Directives
Loss & Grief
Child/Adolescent Safety
Domestic Violence/Abuse
10.
Suggestions of other programs or activities you would like to see offered:
 

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PARTICIPANT AVAILABILITY:
 
Please check all times that you would be available and willing to participate in a program and/or activity:
 
11.
Morning
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
12.
Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
13.
Evening:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Thank you for taking time to complete this survey. Your input is very important in helping the Health & Wellness Ministry better serve you.  The information in this survey will be kept confidential.  General results will be shared with the congregation after the results have been tabulated.

 

If you are interested in learning how you can become better involved with this ministry, please contact Rebekah Adams at rwadams1130@hotmail.com.