Community Health Assessment
1.
Name (First and Last) Optional
2.
What is your age
18-24
25-34
35-44
45-54
55-64
65+
3.
What is your gender?
Female
Male
Other (specify)
4.
What District do you live in?
District 1
District 2
District 3
District 4
District 5
District 6
District 7
5.
In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
6.
Do you have high blood pressure
Yes
No
7.
Are you diabetic?
Yes
No
8.
Are you pre-diabetic?
Yes
No
9.
Do you use commercial tobacco products (Check all that apply)
Cigerettes
Chewing Tobacco
Vaping
Other
None
10.
About how many alcoholic drinks do you have each week?
0
1-4
5-8
9-12
13-16
More than 16
11.
In a typical week, how many days do you exercise?
I don't regularly exercise
Once a week
2 to 4 days a week
5 to 7 days a week
12.
Do you have access/membership to a gym?
Yes
No
13.
In the past 30 days, how many times did you eat out at restaurants or fast food?
Never
1-3 times
4-6 times
7-9 times
10 or more times
14.
Which activities would you be interested in? (Check all that apply)
Fit Camps
Water Aerobics
Culture Classes (Fancy Dance Lessons, etc....)
Basketball Camps (or anything sports related)
Open gym activites
Elders Chair Exercises
Nutrition Classes
5K Running Events
Walks
Health Fairs
15.
Please identify the three most important health issues in your community.
Aging issues, such as Alzheimer's disease, hearing loss, memory loss or arthritis
Cancer
Chronic Pain
Dental Health
Diabetes
Early Sexual Activity
Heart Disease
Lung Disease
Obesity
Mental Health
16.
Please identify the three most important unhealthy behaviors in your community.
Angry behavior/violence
Alcohol Abuse
Child abuse
Domestic violence
Drug abuse
Elder abuse
Lack of exercise
Not able to get a routine checkup
Poor eating habits
Reckless driving
Risky sexual behavior
Smoking
17.
What other services would you like to see offered from your Kiowa Tribe Health Program?
18.
How would you rate your Kiowa Tribe Health Program?
1 star
2 stars
3 stars
4 stars
5 stars
