Faith Community Health Needs Survey In order to help develop the Health Ministry Program at First Presbyterian Church, the Faith Community Nurses would appreciate your thoughts regarding the following questions. All information will be kept confidential. OK Question Title * 1. Your age? Under 20 20–29 30–39 40–49 50–59 60–69 70-79 over 80 OK Question Title * 2. Please check topics you would like to receive support for and/or learn more about: Blood pressure Infant care/Nursing Cancer Parenting Stroke/heart disease Grandparenting Weight management Parenting a child or teen with Arthritis/Joint Health Extended illness, mental Chronic Pain Health issues, or special needs Diabetes Freedom from smoking Health Maintenance (immunizations etc.) Know Your Medications Exercise Caring for aging relatives Healthy eating Caregiver stress/respite care Advance Directives/End of life planning Palliative and Hospice care Facing the Challenges of Aging Alzheimer’s disease/dementia First aid safety/CPR instruction Bereavement Home safety Emergency Preparedness Addiction/Addiction Support Anxiety/Depression OK Question Title * 3. Other topics: OK Question Title * 4. Would you attend a class on any of the above topics? Yes No OK Question Title * 5. If yes, when would be a good time to attend a class? Weekdays daytime Weekdays evening Saturday morning After 2nd service OK Question Title * 6. How would you like to see the faith community nurse/health ministry team used? Visitation of hospitalized/homebound Screening programs such as blood pressure Support Groups such as family caregiver group Health Education/support both 1:1 and in group settings Liaison to community resources OK Question Title * 7. Additional thoughts and comments: OK Question Title * 8. Please leave your name if you would like to speak with a community nurse with any needs or suggestions Name Email Address Phone Number OK DONE