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Community Health Questionnaire - English
Please answer the following questions honestly. Your responses will help us improve health services in our community. All answers are confidential.
Demographic Information
Age:
Under 18
18–24
25–34
35–44
45–54
55–64
65 or older
Gender:
Female
Male
Non-binary
Prefer not to answer
Race/Ethnicity: (Select all that apply)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Prefer not to answer
Other:
Housing Status:
I have stable housing
I am temporarily staying with others
I am in a shelter or transitional housing
I am living in a vehicle or outdoors
Other:
