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:

Age:

Gender:

Race:

Marital Status:

Employment Status:

Health Insurance:

Primary Care Physician:

HEALTH INFORMATION:

Please check if you currently have, or have a history of any of the following conditions:

HEALTH PROGRAMS/ACTIVITIES:

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.

Suggestions of other programs or activities you would like to see offered:

PARTICIPANT AVAILABILITY:

Please check all times that you would be available and willing to participate in a program and/or activity:

Morning

Afternoon

Evening:

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.