ORCHID Program Heart Health Survey
The Institute for Successful Leadership thanks you for your interest!! The ORange County Health Improvement Design (ORCHID) program is sponsored by the Florida Department of Health and we want to hear from you about how you keep your heart healthy. Please take about 10 minutes to tell us, and together, we can help all of Holden Heights to step into 2021 with healthier hearts. Thank you again, and be well!!!
Email address *
Last four digits of your cell number *
Zip Code *
Gender *
Required
What is your primary language? *
Required
What is your racial background? *
Required
What is your ethnic background? *
Required
What is your age range?
In the past 5 years, have you or anyone in your family been diagnosed with the following conditions:
Yes
No
I don't know
High Blood Pressure
Stroke
Cancer
Diabetes
High Cholesterol
Are you overweight?
What do you do to stay in shape physically? (Check all that apply)
What are some things that stop you from making healthier choices?
Do you:
Yes
No
I don't know
Smoke Cigarettes, Cigars or E-Cigarettes
Drink more than 3 alcoholic drinks per week
Live with someone who smokes
Live with high levels of stress
Believe you live a healthy life
Clear selection
What do you think the most important health topics are?
Least Important
Important
More Important
Most Important
Healthcare costs
Transportation
Mental Health
COVID-19
Cancer
Drug Abuse
Smoking
Alcohol Abuse
Other
Clear selection
Thank you!!!
On behalf of the Institute for Successful Leadership and the Florida Department of Health, Office of Minority Health & Health Equity, thank you for your participation. We look forward to helping you step into 2021 with a healthy heart!!! THANK YOU!!!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms