(Your Church Name)
HEALTH MINISTRY

CONGREGATIONAL ASSESSMENT

Directions: This congregational assessment is to be filled out by each member in the congregation as a means of assessing the congregation’s needs and resources.

Name:______________________________________________ Age:______

Names and Ages of Children/Dependents:
_________________________________________________________________________

Occupation:______________________________________________________________

Telephone Number:__________________________________

WHAT ARE YOUR HEALTH CONCERNS? (please list any that come to mind)

WHICH OF THE FOLLOWING HEALTH ISSUES ARE (or should be) CONCERNS OF THIS CONGREGATION?

___AIDS	___Elder Care
___Child Care	___Drugs
___Environment	___Exercise
___Grief	___Adolescent Care
___Nutrition	___Parenting
___Pregnancy	___Stress management
___Death and dying	___Alzheimer’s Disease
___Adult Diabetes	___Juvenile Diabetes
___Heart Disease	___Other disease information:
Types:_______________________________

WHAT SERVICES WOULD YOU LIKE TO SEE PROVIDED IN THIS CONGREGATION?

__Exercise Class	___Health Screenings (blood pressure, blood sugar, etc)
__Health Counseling	___Wellness Education
__CPR and First Aid classes	___Babysitting classes
__Assistance with Advance Directives	___Arrangements for transportation to clinics, doctors, hospital
__Support Groups for the following:
___AIDS	___bereavement
___Alzheimer’s Disease	___caregiver
___eating disorders	___learning disabilities
___cancer	___Others: (please list)
___Other Services not listed:

WHAT WOULD YOU BE WILLING TO DO?

___babysitting	___join a support group
___provide transportation	___visiting
___telephone contacts	___writing cards/letters
___join a prayer team	___Help with Health Newsletter
___Serve on a Congregational Health Ministry Team	___Help with Health Library
___Help with Health Bulletin Board	___Help take Blood Pressures
___Assist with Health Forums/Seminars	___Other: (please specify):_______________________

Thank you for taking the time to complete this form. Your comments will be very helpful in prioritizing health programs within our congregation.