Living Well: Workshop Interest Inventory

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Chronic Disease Self-Management is an evidence-based, 6 week curriculum designed to teach people how to improve their overall health and well-being while living with a chronic condition. These courses are also open to those caring or living with someone with a chronic condition.

At Homage, we are proud to offer this program in the community. Help us plan for the future by answering the following questions.

Your email address will be entered in a random drawing to receive an Amazon gift card as a thank you for your participation. We will only contact you using this email if your name is drawn.

Email *

Do you have a chronic condition OR are you caring for someone who has a chronic condition? *

I have a chronic condition

I am caring for someone with a chronic condition

I have a chronic condition AND I am caring for someone with a chronic condition

None of the above

Based on the descriptions of the following curriculum, check the boxes of those you would be interested in attending *

Living Well with Chronic Conditions series focuses on problems common to people living with recurring health conditions such as asthma, heart disease, arthritis and hypertension.

Living Well with Diabetes series is designed for people with Type 2, or pre-diabetes, and includes topics like how to manage blood sugar, plan healthy meals and prevent complications.

Living Well with Chronic Pain series addresses medication management, the differences between acute and chronic pain, and exercise plans specifically designed for people with chronic pain.

None of these would interest me

Required

Have you attended any of the Living Well Workshops in the past? *

Yes

If yes, do you have any feedback about the workshop you attended?

Do you have access to transportation?

Yes

Yes, but it's unreliable or limited

Yes, but often I don't feel well enough to leave house

Clear selection

How do you enjoy learning? Check all that apply.

In-person

Online

Individual

Group setting

What time of day works for you to attend a workshop? Check all that apply.

Morning (9:00-11:30)

Afternoon (1-3:30)

Evening (5-7:30)

I can't commit to a schedule

What is your zip code? *

Do you live in a senior apartment community that may be willing to provide meeting space OR do you have access to another type of community space (church, meeting room, etc) that may be willing to host these workshops? If yes, are you willing to provide contact information so we can reach out?

Year of birth *

What is your gender identity?

Male

Female

Other:

Clear selection

Which racial or ethnic groups do you identify with? Check all that apply.

White/caucasian

Asian or Pacific Islander

Black or African American

Native American or Alaskan Native

Hispanic or Latino

Other:

Thank you for taking the time to complete this survey. If you would like us to include you on our mailing list and keep you updated on future Living Well workshops being scheduled, please enter your contact information below before you submit

Email address for upcoming workshop information

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms