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Church of the
Epiphany |
Epiphany is a Health-Wise Parish
The Church of the Epiphany, founded in 1833 on
the Lower East Side, took up residence on the
Our parish today is taking the lead in a number
of healthcare initiatives, including a Parish Nurse program, Parish Visitors,
and Licensed Eucharistic Ministers who are empowered to bring the Sacrament to all
who desire it in the local hospital community. We are also coordinating the
chaplaincy program for all EMS workers in
Our parish nurses have put together two
questionnaires as a way of learning more about how our health ministries can be
helpful to our parish and community. The first is a general informational
assessment. Please print it out and
return it to the Church office at
The Church of the Epiphany
Health Ministries Questionnaire
Fall
2005
Greetings!
The
Parish Nurses request your help in planning for health ministries at Epiphany.
This questionnaire was designed to gather information about your needs and interests.
There is no need to sign your name unless you want to. All information will be
confidential and will only be used for planning programs in this church. Extra
copies are available at the church office and near the
Please
either bring your questionnaire to church or mail it to us at the church
office. There will also be a place to collect the questionnaires near the doors
of the church.
THANK
YOU for your time and assistance!
The Parish Nurses
__________________________________________________________________
1. My sex is
__male __female. 2. My age
is___________
3. I usually
attend the ___8:00 a.m. ___11:00 a.m. _____6:00 p.m.
___ I do not attend services here but I am
interested in health programs.
4. My
marital status is __single __married __separated __divorced __widow __widower
5. How
far did you go with your formal education?
__Elementary
school __High school __Technical school __College __Masters __Doctorate
6. What
is your employment status?
__work at home __work part-time __work full-time
__I plan to retire in about 5 years __retired
7. Do
you have a wellness program at your place of employment? __Yes __No If so, do
you utilize it? __Yes __No
8. How
would you rate your health? __Excellent __Good __Fair __Poor
9. Do
you engage in regular exercise? __Yes __No
10. Do you have an annual physical exam? __Yes No
11. Do you have
any of the following conditions?
__Heart disease __High blood pressure __Arthritis
__ Diabetes ___Lung disease __Cancer
12. Do you have physical limitations due to health conditions?
__Yes___ No.
If
so, what kind? ___________________________
13. Educational
Programs and Support
Groups can be developed to meet the interests and needs of people at The Church
of Epiphany. Please indicate if you would be interested in participating in any
of the following.
You may mark as many as you
would participate in.
— living with chronic
illness __divorce
recovery
__loss and grief __coping
with cancer
__weight control __alcoholics
anonymous
__caring for an
elderly relative __singles
group
__parenting __smoking
cessation
__exercise groups
__other_________________
14. Which of the groups listed in question 13 do you think is most
needed?
Put a star next to it.
16. The following are areas that could enhance emotional, physical
and
spiritual
health. Please indicate if you would be interested in participating in
any. Mark as many
as you like.
— healthy eating __aging process
__CPR instruction __exercise
__meditation __yoga
__women’s health issues __relaxation
techniques
__men’s health issues __marriage
enrichment
__human sexuality __creativity
__living wills __addiction
__prayer __humor
__interpersonal relationships __childbirth
preparation
__spiritual direction __health
care insurance issues
__ pre-retirement
planning __other_________________________
16. What 3 health promotion areas do you think we need most?
Please number them 1-3.
17. What day of the week would you be interested in attending a
class or a group? S M T W T F S
18. What time of day? __ Morning __Afternoon __Evening
19. Would you need child care in order to participate?
20. What health concern is most important to you?
__Chronic illness __Stress __Related financial issues
__Fitness __Aging
__Substance abuse
__Catastrophic illness __Other_________________
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This page uploaded: August 24, 2005