English version: Sacred Heart Parish Health Needs Assessment

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Dear Sacred Heart Parishioner,

The Sacred Heart Health Ministry has developed this assessment to determine the needs of the Parish and how best to meet these needs. Please take some time to complete this form. All information given will be confidential. Contact information is optional. Your input is very important for the shaping of this ministry.

References: This survey was adapted from ACHM Heath Survey (2016) . St. John Chrysostom Parish Health Survey (1999)

Demographics/Age:

Under 20

21-29

30-39

40-49

50-59

60-69

70-79

80-89

90+

Clear selection

Gender:

Male

Female

Clear selection

Martial stauts:

# of Children/ages:

Other Care Dependents:

Yes

Option 3

Clear selection

If you answered yes to the other care dependents question above please specify below

What language do you speak best?:

Racial/Ethnic Background:

Have you had a change in your occupation (such as a layoff, or life changes, financial difficulties?)

Check the following services/educational programs that you would find most helpful:

Assistance with health resources and/or referrals

Health Screenings (BP, Diabetes, Cholesterol)

Support Groups (Grief/Bereavement, Caregiving, Parenting, Addictions, Weight Control)

Respite Care (Relief for caregivers)

Chore Assistance (Housework, errands)

Disease Prevention/Management (For example: Heart__ Stroke__ Blood Pressure__ Cholesterol__ Arthritis__ Osteoporosis__ Diabetes__ Alzheimer’s Disease/Dementia__

Mental Health___Other______________________________

Back and Neck Health

Mental Health Issues/ Suicide Awareness Training

Substance Use Disorder

Immigration

Death, Dying and Grief

Life Transitions: Adolescence, Menopause, Aging, Palliative Care

Parenting Issues (youngsters, Preteens, Adolescents, Adult Children)

Stress Management

Medical Insurance, Living Wills, Health Care Proxy

First Aid/CPR/AED Certification Training

Nutrition/ Healthy Eating/Weight Loss/Food Resources

Hearing/Vision

Asthma/COPD

Independent Living and Safety in the Home

Aging Family Members and Elder Service

Living with Chronic Illness

Domestic Violence

Physical Activity

Smoking Cessation

A Matter of Balance: Managing Concerns About Falls

Access to Food Programs, Rental and utility assistance

Caregiver Support

Narcan Training

Spiritual Care/Sacraments/Prayers

Transportation/Medical Rides

Living with Chronic Pain

Cancer/Chemo/Radiation

Financial needs/employment/ underemployment

Other

What days and times would you prefer us to host health related programs?

If you would like to leave your name and contact information, we will get back to you on any topic:

Are you interested in joining the health ministry? Please contact us at shphealthministry@gmail.com, or please leave your name/contact information, and we will get in touch with you.

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