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Form_b86k3bbcm_b86k3bd783h06o3l08PXY1QAO
FlowToolKit__Form_Header_Demo
Community Health Survey
FlowToolKit__Primary_Contact_Default
utility:user
Your Information
*
First Name
*
Last Name
Title
*
Email
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Email Type
--None--
*
Email Type
Work
Personal
Other
Phone
No input rendered: Field "FlowToolKit__Contact1_Phone_Type__c" not found in response.
Phone Type
--None--
Phone Type
Work
Mobile
Home
Community_Health_Survey
utility:heart
Health Survey
In general, how would you rate your overall health?
In general, how would you rate your overall health?
Poor
Below Average
Average
Above Average
Excellent
No input rendered: Field "Do_You_Have_A_Regular__c" not found in response.
Do You Have A Regular
--None--
Do you have a regular doctor or clinic you can go to?
Yes
No
I use urgent care or the ER
Not sure
No input rendered: Field "In_The_Past_Year_Have__c" not found in response.
In The Past Year Have
Press Ctrl (Cmd on Mac) + Left Arrow or Ctrl (Cmd on Mac) + Right Arrow to move items between lists. Supports single character navigation. Press CTRL + Space key to select the option.
Available
Cost or no insurance
No transportation
Could not get time off work
No childcare
Long wait for an appointment
Did not feel heard by providers
I have not delayed care
Move selection to Chosen
Move selection to Available
Chosen
In the past year, have you delayed care for any of these reasons? Choose all that apply.
Cost or no insurance
No transportation
Could not get time off work
No childcare
Long wait for an appointment
Did not feel heard by providers
I have not delayed care
No input rendered: Field "In_The_Past_12_Months__c" not found in response.
In The Past 12 Months
--None--
In the past 12 months, did you worry that food would run out before you could buy more?
Often
Sometimes
Never
Prefer not to say
Additional Questions
How would you rate your stress or mental wellbeing lately?
How would you rate your stress or mental wellbeing lately?
Struggling
More bad days
Average
More good days
Doing well
No input rendered: Field "Which_Health_Services_Would_Help__c" not found in response.
Which Health Services Would Help
Press Ctrl (Cmd on Mac) + Left Arrow or Ctrl (Cmd on Mac) + Right Arrow to move items between lists. Supports single character navigation. Press CTRL + Space key to select the option.
Available
Free clinic days
Mental health counseling
Dental care
Vision and glasses
Blood pressure and diabetes screening
Vaccinations
Fitness and walking groups
Nutrition classes
Move selection to Chosen
Move selection to Available
Chosen
Which health services would help you and your neighbors most? Choose up to three.
Free clinic days
Mental health counseling
Dental care
Vision and glasses
Blood pressure and diabetes screening
Vaccinations
Fitness and walking groups
Nutrition classes
No input rendered: Field "What_Is_The_Best_Way__c" not found in response.
What Is The Best Way
Press Ctrl (Cmd on Mac) + Left Arrow or Ctrl (Cmd on Mac) + Right Arrow to move items between lists. Supports single character navigation. Press CTRL + Space key to select the option.
Available
Text message
Email
Phone call
Flyer or door hanger
Community event
Social media
Move selection to Chosen
Move selection to Available
Chosen
What is the best way to reach you about health resources?
Text message
Email
Phone call
Flyer or door hanger
Community event
Social media
Is there anything else we should know about health needs on your block?
Is there anything else we should know about health needs on your block?
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Form Template: Community Health Survey