Community Health Trend Assessment
Help us understand current health trends in your community by sharing your experiences and perceptions.
Please provide your full name.
First Name
Last Name
What is your age group?
*
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
What is your gender?
*
Male
Female
Non-binary
Prefer not to say
Other
What is your primary area of residence?
*
Please Select
Urban
Suburban
Rural
Other
How would you rate your overall health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Please indicate how often you engage in the following health behaviors:
*
Rows
Never
Rarely
Sometimes
Often
Always
Eat fruits and vegetables
1
2
3
4
5
Exercise (30+ min/day)
6
7
8
9
10
Get enough sleep (7+ hours/night)
11
12
13
14
15
Attend regular health check-ups
16
17
18
19
20
Avoid tobacco products
21
22
23
24
25
In the past year, which of the following health concerns have you or your household experienced? (Select all that apply)
Chronic illness (e.g. diabetes, heart disease)
Infectious diseases (e.g. flu, COVID-19)
Mental health challenges
Substance use issues
None
Other
How would you rate the availability and quality of the following community health resources?
*
Rows
Poor
Fair
Good
Excellent
Primary care clinics
26
27
28
29
Mental health services
30
31
32
33
Health education programs
34
35
36
37
Emergency services
38
39
40
41
What do you think are the most pressing health issues in your community? (Select up to 3)
*
Chronic diseases (e.g. diabetes, heart disease)
Mental health
Substance abuse
Infectious diseases
Access to healthcare
Environmental health (e.g. air/water quality)
Violence/safety
Nutrition/obesity
Other
How have community health trends changed over the past 5 years, in your opinion?
*
Significantly improved
Somewhat improved
Stayed the same
Somewhat worsened
Significantly worsened
Please share any additional comments or suggestions regarding community health in your area.
Submit Assessment
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