1. Please note your medical history/ conditions?

2. Please note medications you are currently taking? (prescription and over the counter)

3. What medical/health issues would you like further education on?

4. What medical issues or conditions do you and your family have concerns about?

5. What is your personal definition of health?

6. What do you hope for or envision for the PUMC Parish Health Team?

7. How do you feel that you and your family could most benefit from the Parish Nurse Ministry and Parish Health Team?

8. Are you interested in being a part of the Parish Nurse Health Team?