DFW Faith Health Collaborative Needs Survey Membership Health Assessment * 1. Please tell us some basic information about you and your family.Including yourself, how many people make up your current household? 1 2 3 4 5 6 7 Other (please specify) OK * 2. What is your gender? Male Female OK * 3. What is your age? OK * 4. Do you have health insurance? Yes No OK * 5. Does your health insurance adequately cover your needs? Yes No OK * 6. Does your health insurance adequately cover your family members’ needs? Yes No OK * 7. What is your zip code? OK * 8. What is your current education level? Less than high school Some high school High school diploma Some college College degree or more OK * 9. Do you have a personal physician/doctor? Yes No OK * 10. Do you have one or more of the following conditions/problems? (check all that apply) Alzheimer’s/Dementia Asthma Breast cancer Cholesterol problems Diabetes Depression Heart disease Alcohol/Drug abuse High blood pressure Mental health issues Prostate cancer Other cancers End stage renal disease HIV/AIDS Smoking Other (please specify) OK * 11. Which types of physical activity do you enjoy doing? (check all that apply) Walking Running Playing individual/team sports Swimming Dancing Cycling Yard work/ Housecleaning Strength training Hiking Water aerobics Other (please specify) OK * 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? Yes No OK * 13. How many days a week would you say that you get moderately intense physical activity? 1 2 3 4 5 6 7 OK * 14. On days when you do get moderately intense physical activity, how long do you exercise for? 15 minutes 30 minutes 45 minutes 60 minutes 75 minutes 90 minutes 105 minutes OK * 15. How do you feel about changing/increasing your physical activity on a regular basis? Not ready to change Thinking about change Preparing for change Actively changing behaviors Maintaining changed behaviors Stopped changing behaviors OK * 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? I eat all of these just about always I eat all of these except where allergies or restrictions keep me from it I eat most of these I eat some of these I don’t really follow these recommendations OK * 17. In thinking of adopting healthier nutrition habits, how do you feel about changing your behaviors to help you eat healthier? Not ready to change Thinking about change Preparing for change Actively changing behaviors Maintaining changed behaviors Stopped changing behaviors OK * 18. How would you rate your overall health? Excellent Good Fair Poor OK * 19. If your faith body were to offer education on a health topic, which ones would you be most interested in? Exercise program/ groups Glucose/ Cholesterol screenings Nutrition Weight loss support groups/program Diabetes support groups/program Alcohol/substance abuse support groups Healthy cooking classes Blood pressure checks Cancer screenings (breast, prostrate etc.) Stress management classes Support for persons with mental illness First aid and CPR Health access (obtaining insurance) Care for the elderly Other (please specify) OK * 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. Food Housing Repair Counseling/ Grief support Rental / Mortgage Assistance Special Prayer Learn how to become a DCT member Academic help for my children School tuition or scholarship support Medical help Assistance with my Family relations Housing Utilities Assistance Help to care for a senior relative Care for the elderly Financial/ budgeting assistance OK * 21. (Optional) Please list other ways that DCT can be a caring church community. OK DONE