Immaculate Conception Health Ministry 

Parish Survey

                                  
         Name (optional):                          E-mail Address (optional): 

         Would you be interested in any of the following health needs and concerns? (Check all that apply.)

        1.   End of Life Issues                                                                            Would you be interested in having a health fair? This might
        2.   Visits to Shut-Ins                                                                             be a Sunday afternoon from 1 or 2 to 5 PM including light
        3.   Elder Care                                                                                        refreshments, activities for children (face painting, etc.) and
        4.   Hospital Visits                                                                                 using professionals from Immaculate Conception. Other groups
        5.  Smoker Cessation Program                                                             can be invited for booths as well, Saint Mary's Hospital, American
        6.   Exercise Program/Aerobics                                                             Diabetic Association, etc. The focus would be on wellness and
        7.   Blood Pressure Checks                                                                    stewardship of our bodies.
        8.   Glaucoma Checks
        9.   Mental Health                                                                                 Yes  (10)  No   (11)
        12. Drug Intervention
                                                                                                                             Health Fair: (Might include the following. Please check the ones
         Monthly Education Programs                                                                   you think would be of interest.)

        14. Living with Diabetes                                                                      15. Cholesterol Check (requires fasting)
        16. Stress Reduction                                                                             17. Blood Sugar Check (requires fasting)
        18. Self-Esteem                                                                                     19. Bone Density Screening
        20. Parenting                                                                                        21. Hearing Screening
        22. Healthy Relationships                                                                    23. Visual Check
        24. Dating Relationships                                                                     25. Nutritional Resources
        26. Conflict Resolution                                                                        27. Body Fat Screening
        28. Anger Management                                                                        29. Depression Screening
        30. Nutrition                                                                                          31. Memory Screening
        32. Medicine Management                                                                   33. Stress Reduction
        34. Pre-retirement Workshop (Medicare Part D)
        35. CPR Training
        36. Other

   Please add any additions and comments you may have. Your comments can be as long as you desire. The input box automatically scrolls down as additional lines are typed