Share the Survey:
 Community Health Advocacy Survey
Identifying areas of potential strength and needs includes working with the individual in providing continuity of care, working with the family to identify positive community actions that can be accomplished to prevent and care for the individual with developmental disabilities.

Health Promotion and Disease Prevention
The survey investigates what makes services and support a person with developmental disabilities would need to live successfully in the community.

1.  Please specify your gender. (Optional)

  Male
  Female


2.  What is the highest level of education you have completed? (Optional)

  Grammar School
  Some High School
  Associate Degree
  Master's Degree
  PhD or Professional Degree (J.D.,M.D.etc.)
Other, please specify


3.  What is your age? (Optional)



4.  Please specify your family status or support.

  Mother
  Father
  Both Parents
  Both Parents and one Sibling
  Both Parents and more than one Sibling
  Siblings only
Other


5.  If you have a primary care provider, how satisfied are you with your primary care provider?

  Very satisfied
  Satisfied
  Dissatisfied
  Very Dissatisfied


6.  Please select the option that best describes your opinion regarding the following.

Strongly agreeModerately agreeSlightly agreeSlightly disagreeModerately disagreeStrongly disagree
I feel I matter a lot to both myself and others
I feel comfortable in my own skin
I have most of the things that make life comfortable
I am content with my life
I am optimistic about future
I have trouble falling asleep and I usually don't get a restful sleep
I find beauty in so many things around me
My past experiences have left me bitter
I am critical of others
I enjoy the company of friends and relatives


7.  How would you rate your health these days?

  Excellent
  Very good
  Good
  Fair
  Poor


8.  How satisfied are you with the following things in your life?

Very satisfiedSatisfiedDissatisfiedVery Dissatisfied
The staff that assist you in activities of daily living
The home you live in
The leisure time you get
Your social interaction in the community in which you live


9.  How would you rate your overall level of happiness?

  Very high
  High
  Average
  Low
  Very low


10.  You will be happy at this very moment if ____________.



11.  Please mention the three things that you think contribute significantly toward your health and happiness.

One 
Two 
Three 


12.  If I had to live my life all over again, I wouldn't change anything.

  Agree
  Disagree


13.  If your answer to the previous question is "Disagree", then please specify that one thing you would like to change about your life.



14.  What is your name?



15.  What is your name?