Community Health Needs Assessment Question Title 1. Gender Male Female Other Question Title 2. Age Under 18 18-29 30-44 45-59 Over 60 Question Title 3. Postcode Question Title 4. At present, how would you rate: Very poor Poor Adequate Good Very good a) Your own general health a) Your own general health Very poor a) Your own general health Poor a) Your own general health Adequate a) Your own general health Good a) Your own general health Very good b) The general health of your family b) The general health of your family Very poor b) The general health of your family Poor b) The general health of your family Adequate b) The general health of your family Good b) The general health of your family Very good c) The general health of your community c) The general health of your community Very poor c) The general health of your community Poor c) The general health of your community Adequate c) The general health of your community Good c) The general health of your community Very good Question Title 5. Which groups of people should have the highest priority for health and wellbeing in your community (please tick up to 3 groups from the list below)? Men Women Children and Young People People aged 65+ People with disabilities People with long-term health conditions Black & Minority Ethnic people Carers Question Title 6. Which of the following do you think are important to keep you well (please tick all that apply)? Connecting to people in your local community Being physically active Take notice - pausing to appreciate the things in your everyday life Learning new skills and information Give something back to those around you Question Title 7. Which of the following do you think are health issues for your community and should be prioritised for future health interventions (please tick up to 3 issues from the list below)? Drugs Alcohol Overweight & Obesity Affordability of healthy food Depression Anxiety Loneliness Sexual Health Question Title 8. Are there any other health issues not listed in Question 7 that you think should be prioritised for future health interventions in your community? Question Title 9. Are the existing community health services in your area meeting your health and wellbeing needs?(for example community pharmacy; home visiting; domiciliary care/home help; etc.) Yes No Question Title 10. Are there any issues preventing you from accessing these community health services at present? (for example mobility issues; a lack of the services available; services not available in your community; etc). Question Title 11. In what ways could existing health services be improved to better meet the future health and wellbeing needs of your community?(for example better funded services; easier access to services in the community; more affordable services; improved referral pathways to community programmes; etc.) Question Title 12. Are there any community health services that you would like to see provided in your local community that are not presently available? Question Title 13. Would you be willing to participate in a future healthy survey? If yes, please provide us with your email address below so that we can contact you directly. Done