Public Health Community Survey
Full Name
Age
Gender
Female
Male
Other
Prefer not to say
Email Address
Address / Neighborhood
1. How would you rate the overall health in your community?
Excellent
Good
Fair
Poor
2. Please select the biggest health concerns in your community (select all that apply):
Access to care
Chronic diseases
Mental health
Nutrition
Substance use
Environmental issues
Other
3. What are the biggest barriers to good health in your community?
4. What community health services do you or your family use most often?
5. What changes would you like to see to improve community health?