Community Health Behavior Assessment Form
Help us understand the health behaviors and needs within your community. Please answer the following questions honestly and to the best of your ability.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How would you rate your overall health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
In the past 7 days, how often did you engage in the following behaviors?
*
Rows
Never
Rarely
Sometimes
Often
Always
Ate at least 5 servings of fruits/vegetables per day
1
2
3
4
5
Engaged in at least 30 minutes of physical activity
6
7
8
9
10
Consumed sugary drinks
11
12
13
14
15
Smoked tobacco products
16
17
18
19
20
Consumed alcoholic beverages
21
22
23
24
25
How often do you use the following preventive health services?
*
Rows
Never
Rarely
Sometimes
Regularly
Routine medical check-ups
26
27
28
29
Dental check-ups
30
31
32
33
Vaccinations
34
35
36
37
Screenings (e.g., blood pressure, cholesterol, cancer)
38
39
40
41
In the past month, how often have you felt stressed, anxious, or down?
*
Never
Rarely
Sometimes
Often
Always
What are the main barriers that prevent you from adopting healthier behaviors? (Select all that apply)
Lack of time
Cost of healthy options
Limited access to facilities or services
Lack of motivation
Lack of knowledge
Other
Are you interested in participating in community health programs or workshops?
Yes
No
Maybe
Please share any additional comments or suggestions regarding community health.
Submit Assessment
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