St. Elizabeth Seton Catholic Church
Naperville, Illinois

2. Male Female

3. Your Age: Under 20 20-29 30-39 40-49 50-59 60-69 70+

4. Ages of dependents living in your home:

5. Are you responsible for the care of a chronically ill/disabled individual? Yes No

6. What county do you live in?

7. Do you have family in a local nursing/retirement home? Yes No

8. Do you have any transportation issues in regards to your health care? Yes No

Personal Health Status: Please check conditions which affect your life:

Heart Disease	Lung Disease	High Blood Pressure	Diabetes	Stroke
Cancer (type)		Arthritis	Mental Illness	Depression
Addictive Behavior	Physical Disability	Other

The following are health promotion programs that enhance our emotional, physical and spiritual well-being. Please indicate all those you'd be likely to participate in:

Smoking Cessation	Walking for Fitness	Healthy Eating/Weight Control
Health Screenings	Stress Management	Expectant/New Parent Classes
Mens Health Issues	Womens Health Issues	Senior Health Issues
Community Health Resources	Respite Care for Disabled

What is your most important health concern?

Would you be willing to volunteer to help any of these programs? Yes No

Name Phone Email

Comments/suggestions: