Family Health Readiness Survey
Help assess your family's general health preparedness and readiness for common situations. This survey is for planning purposes only and does not collect sensitive medical information.
Household Overview
Household size
*
Age groups present in the household
*
Infants (0-2)
Children (3-12)
Teens (13-17)
Adults (18-64)
Seniors (65+)
Other
Does your family include anyone with ongoing care needs?
*
Yes
No
Health Preparedness Survey
How confident are you in handling a family health situation?
*
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Does your family have a regular primary care provider?
*
Yes
No
Not sure
Which items are currently available at home?
*
First-aid kit
Thermometer
Medications list
Bottled water
Emergency contacts list
Other
Rate your family’s readiness in each area
*
Rows
Prepared
Somewhat prepared
Not prepared
Medications
1
2
3
Emergency contacts
4
5
6
Supplies
7
8
9
Transportation
10
11
12
Communication plan
13
14
15
Planning and Follow-Up
Top readiness gap or concern
*
Preferred follow-up topic or resource area
*
Emergency planning
Medication organization
Child care backup
Elder support
Supply checklist
Other
Best contact method for follow-up
*
Email
Phone
Submit Survey
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