Community Diagnosis Questionnaire

This questionnaire gathers residents' perspectives on quality of life, available services, and local challenges to help guide future community initiatives.

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Full Name

First Name

Last Name

Age

Gender

Male Female Other Prefer not to say

Occupation

How long have you lived in this community?

How would you rate the overall quality of life in our community?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

What are the main strengths of our community?

What are the main challenges or issues facing our community?

What services or resources do you feel are lacking in our community?

How often do you participate in community events or activities?

Never Rarely Sometimes Often Always

How would you rate the accessibility of community services (e.g., healthcare, education, transportation)?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

What improvements would you suggest for our community?

Any additional comments or suggestions?

Would you like to be contacted for follow-up discussions?

Yes No

If yes, please provide your contact information (email or phone number):

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