Health & Well-Being Survey
What city are you currently in?
Select your state:
Select a state
Tennessee
Georgia
Florida
California
New York
Texas
What is your age?
What is your gender?
Select an option
Female
Male
Non-binary
Prefer not to say
Other
Do you have any current physical health concerns?
Do you have any mental or emotional health concerns?
Do you currently take any medications?
Do you have health insurance?
Select one
Yes
No
Not sure
How urgent is your need for medical or mental health support?
Select urgency level
Emergency (need help now)
Soon (within days/weeks)
Routine care or check-up
Anything else you'd like to share?
Submit