Evaluating Community Health and Well-being – Check Your Status

Enter the current date:

Enter some general information:

Enter some additional information.

Enter your date of birth:

Specify the last four of your Social Security Number:

Enter your Marital Status:

Please answer the 4 questions below to help us understand your concerns and needs surrounding your physical and mental health.

1. Please select one that best describes your general health:

2. Regarding your physical health (including physical illness and injury) how many days during the past month did you experience poor physical health?

3. Regarding your mental health (including stress, depression and problems with emotions) how many days during the past month did you experience poor mental health?

4. During the past 30 days, did poor physical or mental health keep you for doing your usual activities, such as work, self-care or recreation?