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?

* 2. What is your gender?

* 3. What is your age?

* 4. Do you have health insurance?

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

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

* 7. What is your zip code?

* 8. What is your current education level?

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

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

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

* 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?

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

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

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

* 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?

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

* 18. How would you rate your overall health?

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

* 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.

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

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