Community Health Assessment Survey

Community Health Assessment Survey — Form Fields

This healthcare template includes 6 fields. Gathers data on community health needs, behaviors, and access to care across a defined population. Informs public health programming and resource allocation decisions. Free to customize and use on ZenBuild.

• What is your age group? (dropdown selection, required) — options: 18–24, 25–34, 35–44, 45–54, 55–64, 65 or older
• Do you currently have health insurance? (multiple choice, required) — options: Yes, No, Not sure
• Which of the following health issues are concerns in your community? (checkboxes, required) — options: Diabetes, Heart disease, Mental health, Substance use, Obesity, Access to care
• How would you rate access to healthcare services in your area? (rating, required)
• What is the biggest barrier to accessing healthcare for you or your family? (dropdown selection, optional) — options: Cost / lack of insurance, Transportation, Language barrier, Long wait times, No primary care provider, No significant barrier
• What health programs or services would you like to see in your community? (long text, optional)