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For more information about Knapp Medical Center’s Valley Health Seminars, please contact us at 969-5237.

Seminar Attended/Viewed:

Is this your first time to attend/view a Valley Health Seminar?

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No

If not, please list previous seminars:

Was the information presented helpful?

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If you could change one thing about this seminar to make it better, what would that be?

Suggested topics for future Seminars?

How did you hear about today's seminar?
Newspaper Ad	Website	Word of Mouth	Mailer	Other:

What do you believe is the greatest need in your community in ourder to have a "healthy community"?
What do you believe is the most positive feature of your community as it relates to health?

Please check 6 items you feel have the most negative impact on the health of people in your community.
Work-Related Health Issues	Access to HealthCare Facilities	Affordability of Care
Sexually-Transmitted Diseases	Environmental Health	Planning for Disasters
Preventable Accident	Diabetes	Cost of Drugs
Physical Abuse	Lack of Financial Resources	Childhood Illnesses
Mental Illness	Respiratory Diseases	Cancer
Availability/Lack of Transportation	Veterans' Health Needs	Colonias
Strokes	Pregnancy-related Health Problems	Water Problems
Education	Rehabilitative Care	Heart Diseases
AIDS	Lack of Knowledge about Preventative Healthcare	Language/Cultural
Violence	Teen Sexual Activity	Availability of Healthcare Facilities
Lack of Health Insurance	Substance Abuse	Other:
Nutritional Disorders	Long Term Care

Which from your selection do you think has the most negative impact?

Gender:
Male	Female

Age:
Under 20 Years of Age	21-49 Years of Age	50-70 Years of Age	71+ Years of Age

Ethnicity:
Hispanic	Non-Hispanic

Residency:
Lifetime Resident	Fulltime Resident	Seasonal Resident	Resident for # Years

City:
Name: