WELLNESS COMMITTEE SURVEY: WINTER/SPRING 2015

To Port Ludlow Residents:

The Health & Wellness Committee has been active in the Port Ludlow community for two years now. We believe that it is time for some feedback from PL's residents both with respect to past Committee efforts as well as desirable activities for this coming year. Please take a few minutes and download, print out and answer the few questions in this short Survey (Click!). You can also ignore, add to or change our questions or send us your comments and suggestions by using the back of the form or get them to us in any other convenient way.

You may hand your filled-out questionnaire to any member of the Committee, send it to P.O.Box 65057 in Port Ludlow (98365) or scan it in and send the scan by Email to plhealth.org(at)gmail.com. We will try to make the form also available at other venues and collect the filled-out form right there. We are also establishing an address list for those of you who would like to receive occasional information from the Health & Wellness Committee by Email, would like to be part of a loosely connected "Health & Wellness Group" and/or be more involved on the Port Ludlow Village Council Health & Wellness Committee.

  1. Have you heard about the Port Ludlow Village Council's Wellness Committee?______
    If yes, how did you hear about the Wellness Committee?_________________________

  2. How important do you consider the activities of the Wellness committee?
    Committee Activities Very Important | | Important | | Not Relevant |
    a. Wellness Forums
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    b. Showing of Videos from Forums
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    c. One-on-One Health Information Counseling
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    d. Support Groups
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    e. Educational Resources:
    --- Pamphlets/Wellness Notebooks
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    --- Website: plhealth.org
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    --- Health-Information: Individual Assistance
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  3. Which Wellness Forums/ Topics you have attended or heard about stand out for you during the last two years?________________________________________

  4. The following topic ideas are presently being considered for the 2013/14 program.
    FORUM TOPIC Is Topic Important? Would you attend?
    | Yes | | Maybe | | No |             | Yes | | Maybe | | No |
    Back Pain Management and Rehabilitation
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    Dementia & Early Intervention
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    Stroke & Tele Stroke Protocols & Rehab
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    Health Care Coverage /Medicare Update
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    New Electronic Patient Records
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    Alternatives to Aging at Home
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    Your Suggestions of Topics:_____________________________________________________

  5. Please circle all media you read to learn about events related to wellness & health in Jefferson or Kitsap County?
    -- PL Voice -- PT Leader -- Peninsula Daily News
    -- Kitsap Sun -- Website(s) PLHealth.org, etc. -- Community Email "Blasts"
    -- Posters on bulletin boards in public places (where?)     -- Others:__________________

  6. Please circle all counties/places you use for health providers to meet your medical needs?
    -- Jefferson/Port Ludlow -- Jefferson/Port Townsend    -- Kitsap/Poulsbo
    -- Kitsap/ Bremerton/Silverdale -- Clallam/Sequim-Port Angeles     -- King/Seattle
    -- Snohomish/Edmonds, Everett    -- Pierce/Tacoma

  7. Suggestions for Forums, Support Groups, or other educational Wellness Resources:

    ____________________________________________________________________________

    Thank you for your feedback! Please use the back of this page if you have further comments or suggestions.

    Name (optional)_____________________ Tel #:_______________ Email:_________________

    Would you like to receive occasional Emails with health information / updates? ___ Yes ___ No