To help plan for health ministry in our faith community, your assistance in answering the following questions is important. There is no need to sign your name unless you would like to be contacted. All information is confidential and will be used for planning programs in our congregation.

Congregational Health Ministry Survey

Your age
Marital Status
How do you rate your health?
Do you engage in regular exercise?

Current Health Status
 Please check if you CURRENTLY have or have  any of the following conditions.
Past Health Status
Please check if you PREVIOUSLY have had  any of the following conditions.
Support Groups
Support groups can be developed to meet the interests of the greatest number of people. Please indicate if you would participate in any of the following. You may mark as many as you would participate in on a regular basis.
Please explain:
**Parenting - the ages of children under your care.
**Other - the type of support group you are interested in that is not listed.
Health Promotion/Education Classes
The following are health promotion/education classes that may enhance your emotional, physical and spiritual health. Classes will be developed to meet the interests of the greatest number of people. Please indicate if you would participate in any of the following. Mark as many as you have interest.
What day of the week and time would you attend a class or group?
If you have had experience in any health topic and would be willing to teach or share your experience, please share your name and contact number below:
Interest in Volunteering?
Would you be interested in sharing some of your time as a volunteer? If so, please indicate your interest and share your name and contact number below.
This field is for validation purposes and should be left unchanged.