JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Comox Residents: Book a Community Health "Check-Up" with Dr. Jonathan Kerr
- Open to all residents of the Town of Comox (by phone, zoom, or in-person)
- Please note: This is not a medical appointment
Sign in to Google
to save your progress.
Learn more
* Required
Email
*
Your email
Healthy Community, Healthy People, Healthy Environment
What is most important to you? (please select up to 5)
*
Strong schools
Inclusion and respect for diversity
Access to local jobs/employment
Availability of local healthy food
Bike lanes, routes, and connectivity
Clubs, organizations and opportunities to volunteer
A sense of belonging to a community
Parks and recreational facilities for healthy activity
Preserving the Town's tree canopy
Protecting our forests, ocean, and wildlife
Creative arts and cultural activities
Addressing the opioid crisis
Mental health support
Supporting our local business community
Access to childcare
Personal health and well-being
Having/Finding a Family Doctor
Addressing climate change and pollution
Clean air to breathe
Security of having affordable housing
Community safety
Citizen participation and advocacy
Our relationship with K'ómoks First Nation
Safe and efficient traffic routes
Other:
Required
Survey adapted from the Canadian Index of Wellbeing
Would you like to have a Comox Community Health Check-up conversation with Dr. Kerr to discuss which issues are most important to you? (If yes, Dr. Kerr and/or someone from his team will contact you.)
*
Yes, by phone
Yes, by email
Yes, by zoom
Yes, in person (i.e. a "home visit" discussion at your front door)
Yes, in person for a group discussion (i.e. meeting at a local park)
Not at this time
Other:
The best time (or day of the week) for me to connect with Dr. Kerr is:
Your answer
Name:
*
Your answer
Home address:
*
Your answer
Phone number:
*
Your answer
My age is:
<20
20-30
30-40
40-50
50-60
60-70
70-80
>80
Clear selection
Is there anything else you would like to add?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms