What do patients want from the Guelph Family Health Team Question Title * 1. What is your age? <20 21-29 30-39 40-49 50-59 60-69 70-79 80 or older Question Title * 2. Are you: Male Female Question Title * 3. Do you have any of the following risk factors (circle all that apply)? Smoker Overweight Inactive (less than 20 minutes/day) Other (please specify) Question Title * 4. Have you ever been told that you have any of the following (circle all that apply)? Diabetes Arthritis Lung problems (COPD, asthma) Previous stroke High lipids High blood pressure Heart Disease (angina, previous heart attack, bypass, congestive heart failure, etc.) I'm not sure if I have any of these Other (please specify) Question Title * 5. Which program would you participate in if it were offered by the Guelph FHT (please check all that apply)? Achieving healthier mood Quitting smoking Stress management Osteoporosis Healthy eating Cooking class Grocery store tour Physical activity Raising healthy children Healthy pregnancy Healthy menopause Health self-assessment Healthy aging Lung health (asthma, COPD) Preventing chronic disease Chronic pain self-management Health self-management Meal planning for healthy living Other (please specify) Question Title * 6. Would you attend any of these clubs if they were offered by the Guelph FHT (please check all that interest you)? Walking club Running club Cooking club Strength training club Health discussion group Other (please specify) Question Title * 7. Where would you prefer to go to participate in these services? North Guelph (Woodlawn Road area) East Guelph (Imperial Road area) West Guelph (Victoria Road area) South Guelph (Clair Road area) Downtown Other (please specify) Question Title * 8. What time commitment would best suit your needs? Group sessions once weekly for 4-6 weeks (ie. an exercise program/education session) Group sessions twice weekly for 4-6 weeks (ie. an exercise program/education series) One session for information and education only (ie. a lecture, web video, taped video) Other (please specify) Question Title * 9. What time of the day would best suit your needs? Mornings Afternoons Evenings Question Title * 10. What day of the week is best for you (check all that apply)? Monday Tuesday Wednesday Thursday Friday Other (please specify) Question Title * 11. What other programs would you like to see the Guelph FHT offer to create a more healthy community? Question Title * 12. What things do you need help with to improve your own health and /or wellness? Question Title * 13. Do you do more than 2.5 hours of physical activity per week (ie. walking, playing sports, swimming, etc.)? Yes No Question Title * 14. If yes, how many times per week do you do physical activity? Question Title * 15. If no, what stops you from doing physical activity? No time Not sure what to do No equipment Can't afford it Pain with activity Live in the Country No motivation No one to go with Bad weather (rain, snow, etc.) Why exercise when I have a vehicle Can't find something I like to do Other (please specify) Question Title * 16. Would you borrow physical activity equipment from the Guelph FHT to try out if it was available? Yes No Question Title * 17. Please specify what you would borrow if it was available: Exercise videos Elastic resistance bands Walking poles Light weights Skipping ropes Other (please specify) Question Title * 18. Who is your family doctor (optional)? Question Title * 19. Do you have any additional comments or suggestions? Done