Membership Health Assessment

Please tell us some basic information about you and your family.
Including yourself, how many people make up your current household?

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* 1. Please tell us some basic information about you and your family.
Including yourself, how many people make up your current household?

What is your gender?

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* 2. What is your gender?

What is your age?

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* 3. What is your age?

Do you have health insurance?

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* 4. Do you have health insurance?

Does your health insurance adequately cover your needs?

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* 5. Does your health insurance adequately cover your needs?

Does your health insurance adequately cover your family members’ needs?

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* 6. Does your health insurance adequately cover your family members’ needs?

What is your zip code?

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* 7. What is your zip code?

What is your current education level?

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* 8. What is your current education level?

Do you have a personal physician/doctor?

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* 9. Do you have a personal physician/doctor?

Do you have one or more of the following conditions/problems? (check all that apply)

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* 10. Do you have one or more of the following conditions/problems? (check all that apply)

Which types of physical activity do you enjoy doing? (check all that apply)

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* 11. Which types of physical activity do you enjoy doing? (check all that apply)

Do you currently get 30 minutes of moderately intense physical activity (for example brisk walking, gardening, dancing, etc.) at least 5 days per week, and preferably every day?

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* 12. Do you currently get 30 minutes of moderately intense physical activity (for example brisk walking, gardening, dancing, etc.) at least 5 days per week, and preferably every day?

How many days a week would you say that you get moderately intense physical activity?

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* 13. How many days a week would you say that you get moderately intense physical activity?

On days when you do get moderately intense physical activity, how long do you exercise for?

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* 14. On days when you do get moderately intense physical activity, how long do you exercise for?

How do you feel about changing/increasing your physical activity on a regular basis?

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* 15. How do you feel about changing/increasing your physical activity on a regular basis?

The USDA Dietary Guidelines recommends your diet should focus on the consumption of fruits and vegetables, whole grains, low-fat milk, lean meats, poultry, fish, beans, eggs and nuts, and is low in fats, cholesterol, salt and added sugars. How often would you say that you follow these recommendations?

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* 16. The USDA Dietary Guidelines recommends your diet should focus on the consumption of fruits and vegetables, whole grains, low-fat milk, lean meats, poultry, fish, beans, eggs and nuts, and is low in fats, cholesterol, salt and added sugars. How often would you say that you follow these recommendations?

In thinking of adopting healthier nutrition habits, how do you feel about changing your behaviors to help you eat healthier?

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* 17. In thinking of adopting healthier nutrition habits, how do you feel about changing your behaviors to help you eat healthier?

How would you rate your overall health?

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* 18. How would you rate your overall health?

If your faith body were to offer education on a health topic, which ones would you be most interested in?

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* 19. If your faith body were to offer education on a health topic, which ones would you be most interested in?

Please check any and all immediate needs you have, so we can plan definite follow-up actions that need to be put in place to assist members of our church family. Feel free to call 972-755-9475 if you are in need of immediate support.

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* 20. Please check any and all immediate needs you have, so we can plan definite follow-up actions that need to be put in place to assist members of our church family. Feel free to call 972-755-9475 if you are in need of immediate support.

(Optional) Please list other ways that DCT can be a caring church community.

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* 21. (Optional) Please list other ways that DCT can be a caring church community.

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