Wellness Survey

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Wellness Ministry Committee Survey

The Wellness Ministry Committee of First Mennonite Church has been asked by the Elders to consider health and wellness issues for our congregation. They are focusing on wellness promotion from a whole person perspective-- body, mind and spirit.

Please answer the following questions:

* Indicates required field

Are you *

Male Female

What is your age? *

Less than 12 12-19 20-40 41-60 61-75 76+

Do you live alone? *

Yes No

If you do not live alone, with whom do you live? *

Family Friends

Do you have someone to call if you need help? *

Yes No

What is your relationship with that person? *

Family Friend Work associate Church associate Other

What is your employment type? *

Full-time Part-time Unemployed Retired

Are you covered by health insurance? *

Yes No

The purpose of this confidential questionnaire is to help us understand your areas of interest and concern. Check all those that you would like to learn more about. *

adolescent health issue advance directives/living wills alcohol/drug abuse/addiction alternative therapies anxiety and/or depression arthritis cancer cardiopulmonary resuscitation caring for aging parents children's health issues communication with others diabetes coping with chronic illness caregiver relief dementia/Alzheimer's disease dental health eating disorders end-of-life issues eye diseases/vision problems exercise family issues forgiveness grief and loss heart disease and stroke heart disease and stroke hypertension (high blood pressure) immunizations/vaccines osteoporosis managing your medications marital issues meditation/prayer men's health issues mental health or problems nutrition/healthy cooking pain management parenting concerns relationship between health and faith pregnancy respiratory/lung diseases sleep disorders/insomnia stress management women's health issues

Would you be interested in joining a support group related to any area of interest you checked above? If you would, please list the group or groups that would be most helpful to you. *

I am in favor of developing wellness programs at FMC: *

Yes No

Do you have any suggestions for the Wellness Ministry Committee? *

Submit

First Mennonite Church of Iowa City
405 Myrtle Ave Iowa City, Iowa 52246
319-338-0302 [email protected]