Welcome to The Health Initiative Information Survey!

Thank you for agreeing to take part in this important survey to identify health needs of the congregation and community.  This survey should only take 4 - 5 minutes to complete.  Be assured that all answers you provide will be kept in the strictest confidentiality.

* 1. What is your age?

* 2. What is your marital status?

* 3. Do you have children in each age group?

* 4. What is your current work status?

* 5. What is your annual income?

* 6. Do you have any health coverage (such as health insurance or government health plan) or are you currently insured by?

* 7. What is your deductible for a standard office visit  and emergency room visit?

* 8. How often do you visit a doctor?

* 9. Have you ever been told that you have a chronic disease?  

* 10. Select any of the items below that have recently  (in the last year) kept you from getting the medical help you needed: