The Community Health Survey Form Template by WPForms is a great solution for conducting health surveys in your communities while gaining actionable insights regarding changes and improvements for health initiatives.
How Does the Community Health Survey Form Template Work?
The Community Health Survey Form Template requires the WPForms Pro License and the Survey and Polls and Signature Addons.
Through the Survey and Polls Addon, you can receive comprehensive community health insights in the form of visual charts and graphs.
Meanwhile, the Signature Addon provides community members with a space to provide their consent to use responses for improving community health services.
Fields Included in the Community Health Survey Form Template
- Personal Information (Optional):
- Name: Collects the name of the respondent for future communications.
- Gender: Gender information for analyzing health trends across demographics.
- Age: Records the participant’s age for insight into age-specific health concerns.
- Email: Captures the email address for future communication and follow-ups.
- Phone: Essential for direct contact or urgent communication needs.
- General Health Status:
- Overall Health Rating: A self-assessment field where participants rate their general health status.
- Chronic Illnesses: Identifies the prevalence of long-term health conditions among participants.
- Hospitalization History: Inquires about any recent hospital stays, shedding light on acute health issues.
- Lifestyle and Wellness:
- Physical Exercise Frequency: Gauges the community’s engagement in physical activities.
- Smoking Habits: Collects data on tobacco usage, a key factor in community health planning.
- Fruit and Vegetable Consumption: Provides insight into the dietary habits of the community.
- Healthcare Access and Utilization:
- Health Insurance Status: Determines the level of healthcare coverage among participants.
- Healthcare Provider Visits: Tracks how often community members seek medical advice or treatment.
- Access to Healthcare Services: Identifies potential barriers faced by the community.
- Community Health Priorities:
- Community Health Issues: Allows respondents to highlight the top health concerns in their area.
- Desired Health Programs: Gathers suggestions for health initiatives or programs that community members feel are needed.
- Consent and Privacy:
- Checkbox: A checkbox field for participants to agree to the terms of data use and privacy.
- Signature and Date: For formal acknowledgment and timestamp of the survey submission.
Sign up with WPForms today and access the Community Health Survey Form Template. It is perfect for healthcare providers, nonprofit organizations, or community leaders who want to make informed decisions for health initiatives.
