Community Health and Environmental Well-being Assessment Form

Project Name: ____________________________ Location: ____________________________ Date: ____________________________

As part of our commitment to promoting health and well-being while considering the energy and environmental aspects of your community, we kindly request your participation in this assessment. Your responses will help us understand the current state of health, well-being, and environmental conditions in the area, enabling us to identify potential areas for improvement. All information provided will be treated with the utmost confidentiality.

  1. Personal Information (Optional):

Name: ____________________________ Age: ____________________________ Gender: ____________________________ Occupation: ____________________________

  1. Physical Health:

a) How would you rate your overall physical health?

□ Excellent □ Good □ Fair □ Poor

b) Do you have any pre-existing medical conditions or chronic illnesses? If yes, please specify:

c) How often do you engage in physical exercise or outdoor activities in your community?

□ Daily □ Several times a week □ Once a week □ Rarely □ Never

  1. Mental and Emotional Well-being:

a) On a scale of 1 to 5, how would you rate your overall mental and emotional well-being in relation to the community's environment?

1 - Very Poor 2 - Poor 3 - Neutral 4 - Good 5 - Excellent

b) Have you experienced stress, anxiety, or negative emotional impacts due to environmental factors in the community? If yes, please elaborate:

c) Do you have access to green spaces or natural areas within the community that contribute to your mental well-being?

□ Yes □ No

If "Yes," please describe their importance to you: _____________________________________

  1. Social Connections and Community Support:

a) How would you rate the strength of social connections and community support within the area?

□ Very Strong □ Strong □ Neutral □ Weak □ Very Weak

b) Are there any community-led initiatives or projects related to energy and environmental sustainability that you actively participate in?

□ Yes □ No

If "Yes," please provide details: __________________________________________________

  1. Environmental Well-being:

a) How would you describe the overall environmental quality in your neighborhood in terms of air and water quality, noise levels, and green spaces?

□ Excellent □ Good □ Fair □ Poor

b) Are there any specific environmental factors that impact your well-being negatively? If yes, please specify:

  1. Access to Energy-Efficient Infrastructure:

a) Do you have access to energy-efficient infrastructure or renewable energy solutions within your community?

□ Yes □ No

If "Yes," please specify any initiatives or technologies available: _______________________

  1. Additional Comments or Suggestions:

Thank you for participating in this assessment! Your valuable input will contribute to our efforts in creating a healthier and more sustainable community. If you have any further comments or concerns, please feel free to share them below:

Note: Your participation in this assessment is voluntary, and all information provided will be used solely for research and analysis purposes. Your privacy is important to us, and your responses will remain anonymous and confidential.