Membership Health Assessment
The Health Ministry Committee would like to ask the congregation to participate in a survey. This survey would help the Health Ministry Committee to identify topics and areas of interest for the Health Committee to focus activities and also to identify interested participants.
Here is the survey, if you would like to print a copy click here for a printable version.
To assure confidentiality of all information provided, DO NOT PUT YOUR NAME on this survey.
1) How many people in your family household are: How many people in your family household are: How many people in your family household are: How many people in your family household are: How many people in your family household are:
under 12____ 12-18 ____ 19-64 ____ Over 65 ____ under 12____ 12-18 ____ 19-64 ____ Over 65 ____
2) How many people in your family household are: Male ____ Female ____ How many people in your family household are: Male ____ Female ____
3) Does anyone in your house hold have one or more of the following conditions?(check all that apply): Does anyone in your house hold have one or more of the following conditions?(check all that apply):
Breast Cancer Diabetes Weight-related issues Alzheimer's/Dementia Asthma Prostate Cancer
High Blood Pressure Depression Heart disease Mental Health Issues
4) The Dietary Guidelines for American recommends that adults get at least 30 minutes of moderately intense physical activity at least 5 days per week, and preferably every day.Please indicate your level of daily physical activity using the following scale:
1 None 2 3 4 5 30 minutes or more
5) For children and adolescents, the recommendation is at least 60 minutes of moderately intense physical activity most days of the week, preferably daily. Please indicate you children's levels of daily physical activity using the following scale: Please indicate you children's levels of daily physical activity using the following scale:
1 None 2 3 4 5 60 minutes or more
6) What types of physical activity do you enjoy doing? (Check all that apply):
Strength training Walking Swimming Playing individual/team sports Running Hiking
Climbing stairs Yard work Chair exercises Housecleaning Wateraerobics Playing actively with children/grand Other ____________________
7) The USDA Dietary guidelines recommends a diet that emphasizes the consumption of fruits and
vegetables, whole grains, low-fat, lean meats, poultry, fish, beans, eggs, and nuts and is low
in fats, cholesterol, salt, and added sugars. Using the following scale, please assess how closely
your diet follows these recommendations:
1 2 3 4 5
Does not meet any Fully meets the
8) Using the following scale, please assess how closely you children's diets follow USDA recommendations:
1 Does not meet any 2 3 4 5 Fully meets the
9) Using the following s ale, please assess how satisfied you are with your current weight.
1 Very satisfied 2 3 4 5 Very unsatisfied
10) Would you like to learn how to eat healthier? ____ Yes ____N0
11) Would you like to learn how to do more physical activities? ____Yes ____No
12) How likely would you or other members of your family be to take part in any of these activities?
| Activity | Would Not Attend | Might Attend | Definitely Would |
| Healthy eating and cooking classes | |||
| Weight management support group | |||
| Healthy recipes contest | |||
| Grocery store tours | |||
| Fitness classes | |||
| Dance | |||
| Low impact aerobics | |||
| Strength training | |||
| Walking group | |||
| Chair exercises | |||
| Breastfeeding classes | |||
| Stroller club | |||
| Community garden | |||
| Health fair | |||
| Sports (Specify__________________ | |||
| Other (Specify:_________________ |
13) What day of the week would be best for you to join these types of activities?
Best day (s) ________________________________________________________
Worst day(s)________________________________________________________
________________________________________________________
14) What would be the best time for you to attend health and fitness activities?
Morning _____ Afternoon ____ Evening ____
Second Section
We want to learn about the abilities and talents of our membership that can help our faith community
develop and implement a health promotion program. Please help by telling us about the personal
skills and interests grained through your education, work experience, family life, hobbies,
or volunteerism.
Your Name ____________________________________________________________________
Address ______________________________________________________________________
City ____________________________ State _________________ Zip ___________________
Phone (home) __________________________ (work) ________________________________
Email ________________________________________________________________________
Are you or a member of your family a (check all that apply):
_____Physicia _____ Coach _____ Public relations/marketing professional
_____Event/meeting planner _____Chef _____ Professional or volunteer fundraiser
_____Physical therapist _____Nurse _____Scout/youth group leader
_____Dietitian/Nutritionist _____Teacher _____Professional or amateur athlete
_____Councilor _____Landscape architect _____Health educator
_____Weight management specialist _____Exercise instructor
Other relevant profession - please specify ____________
Do you or a family member have special skills or interest in: (check all that supply):
_____Writing newsletters _____Typing/word processing _____Sports
_____Creating We sites _____ Gardening _____Cooking
_____Budgeting Program evaluation
What other skills do you have that could be applies to our health promotion program?
_______________________________________________________________________
_______________________________________________________________________
Dou you have other resources/connections that could help with our health promotion program?
Would you be willing to help with any of the following activities? (check all that apply).
_____Health fairs _____Fitness classes _____ Cooking classes
_____Weight loss/ support group _____Community gardening _____Healthy cooking demos.
_____Coaching a sports team _____Health Education materials _____Teaching Health classes