test Please enable JavaScript in your browser to complete this form.Our Mamalilikulla First Nation Mission Statement is: "Working together to build a strong, proud and healthy Mamalilikulla community."When we think of health and wellness, we look at culture, language, mental health, physical health and spirituality as indicators of "health". These indicators are core to an understanding of how we, as Mamalilikulla people keep ourselves balanced and therefore healthy. This survey is meant to collect as much important information from each member as possible in order for us to provide you, the members the very best service we can. Whether it is sending you information on where to go for your health concerns, or creating a workshop to teach you how to make button blankets, we promise to gather all information with you in mind and please note that this information will be held in strict confidence and is meant only to help us help YOU.HOUSEHOLD OCCUPANTS' DEMOGRAPHICSName *FirstMiddleLastGenderMaleFemaleN/AAge Group0-1516-1920-2930-4546-6465+Home PhoneCell PhoneWork PhoneOtherEmail *What is your annual household income?$9,999 or less$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000+Please check all applicable sources:Employed full-timeEmployed part-timeEmployed seasonallyCurrently receiving EICurrently receiving maternity/parental benefitsCurrently receiving Worker’s CompensationCurrently receiving Disability benefitsSelf-employed - Registered companySelf-employed - IncorporatedCurrently receiving income assistanceHow long have you been on income assistance?Status Card #Marital StatusSingleDivorcedMarriedWidowedCommon-LawHow many children/youth ( 0-17 years) live in the household at least half the time?How many of those children/youth ( 0-17 years) are of male gender?How many of those children/youth ( 0-17 years) are of female gender?Are all school-age children enrolled in school?YesNoAre you the child/ren's biological parent?YesNoIf there are any children in the household that are not yours biologically, please list their names here.How many adults (18-65+ years) live in the household at least half the time?How many of those adults ( 18-65+ years) are of male gender?How many of those adults ( 18-65+ years) are of female gender?Please name all household occupants and their relationship to you.How many rooms are in the household (including kitchen, bedrooms, living rooms and finished basement - excluding bathrooms, halls, laundry room and attached shed)?Do you have a disability?YesNoWhat is the effect of your disability?HearingLearningMotor SkillsMental HealthPhysical HealthOtherWhat is the highest level of education or training you have completed (full or part-time)?No formal education/trainingPrimary (K to Gr 7)Some Secondary (Gr 8-12) Please specify belowEvergreen diplomaDogwood diplomaGED diplomaAdult Dogwood/Adult Basic Education diplomaSome technical/trades/vocational training (i.e. BCIT)Advanced certificate/completed (i.e. Journeyman ticket)Some College/UniversityCollege graduation (i.e. Associate degree, college diploma)CHILDCARE INFORMATIONIs/are the child/ren receiving childcare?YesNoDo you go outside the home for childcare?YesNoIf yes, where? If no, who looks after them?What is/are the child/ren's main childcare arrangement?Care in someone else's home by a family memberCare in child/ren's home by a family memberCare in someone else's home by a non-relativeCare in child/ren's home by a non-relativeDaycare centreNursery school/preschoolPrivate home daycareBefore/after school programn/aHow many hours per week does/do your child/ren spend in childcare?CULTURAL INFORMATIONHow important is it that your child/ren learn a First Nations language?Not importantSomewhat importantImportantCan your child/ren speak or understand a First Nations language?YesNoWhat level of understanding does/do your child/ren have of the First Nations language?Basic level (can speak or understand a few words)Intermediate level (can read or carry on a conversation)Fluent levelHow important is it to expose your child/ren to traditional cultural events?Not importantSomewhat importantImportantHas/have your child/ren ever participated in traditional singing, drumming or dancing groups or lessons outside of school hours?YesNoWho is involved in helping your child/ren understand their culture?GrandparentsParentsAunts and UnclesSchool TeachersOther RelativesCommunity EldersOther Community MembersFriendsNo Onen/aHas/have your child/ren ever attended an Aboriginal Head Start program?YesNoHas/have your child/ren ever repeated or skipped a grade?YesNoDoes/do your child/ren have a learning disability?YesNoHow often does your child/ren read or are read to for fun?Every dayA few times a weekOnce a week or a few times a monthLess than one a month or almost neverPHYSICAL ACTIVITY & NUTRITIONHow much does each of your children weigh?How often does your child/ren participate in extracurricular activities such as sport teams or lessons, music groups or lessons, traditional singing, drumming, or dancing groups or lessons?4 times or more per week1-3 times per weekLess than once per weekNevern/aIn the past 12 months, how often did your child/ren eat any traditional foods?Not at allA few timesOftenIn the past 12 months, which traditional foods did your child/ren consume?Land-based animals (i.e. moose, caribou, bear, deer, bison, etc)Small game (i.e. rabbit, muskrat, etc)Freshwater fishSaltwater fishOther water-based foods (i.e. shellfish, eel, etc.)Game birds (i.e. goose, duck, etc)Berries or other wild vegetationBannock, fry breadWild riceCorn soupHow often does your child/ren consume a healthy diet?Not at allA few timesOftenn/aIn the past 12 months, which foods did your child/ren consume?Milk and milk products (i.e. yogurt, cheese)Protein (i.e. beef, chicken, pork, fish, eggs, beans, tofu, etc)VegetablesFruit (excluding juice)Bread, pasta, rice, and other grainsWaterJuiceSoft drinks or popFast food (i.e. burgers, pizza, hotdogs, french fries)Sweets (i.e. candy, cookies)How much time in an average day does your child/ren spend watching TV, reading, working at a computer, and/or playing video games?DENTAL CAREHas your child/ren had any dental care in the past 12 months?YesNoWhen was the last time your child/ren had any dental care?Does your child/ren need dental care?YesNoWhat is the type of dental treatment required?Restorative (i.e. cavities filled)Maintenance (i.e. checkups or teeth cleaning)Dental extractionsFluoride treatmentOrthodontics (i.e. braces)Urgent careHEALTHHas your child/ren been diagnosed with a health condition?YesNoDoes your child/ren have any of the following health conditions?AllergiesChronic anemiaAnxiety or depressionAsthmaADD/ADHDAutismCancerChronic bronchitisCognitive or mental disabilityDermatitis or atopic eczemaDiabetesFetal alcohol spectrum disorderHearing impairmentHeart conditionHepatitisKidney diseaseLearning disabilitySpeech or language difficultiesTuberculosisChronic ear infections/ear problemsArthritisOther (please specify)Blindness or serious vision problems (that glasses can't correct)If you have ever experienced any barriers to health care for you or your child/ren, please indicate as per the following:Waiting list is too longFelt health care was inadequateDoctor/nurse not availableService was not available in areaUnable to arrange transportationCould not afford transportation costsHealth facility not availableNot covered under NIHB/FNHACould not afford childcare costsFelt service was not culturally appropriateDifficulty getting traditional carePrior approval under NIHB/FNHA deniedChose not to see health professionalHas your child/ren been injured in the past 12 months?YesNoWhat type of injury did your child/ren have?Minor cuts, scrapes, bruisesBroken or fractured bonesMajor sprain or strainBurns or scaldsDental injuryOtherConcussionWhat part(s) of the body did your child/ren injure?HeadLegKneeHandArmFootWristAnkleTorso (body)OtherEye(s)Where did the injury(ies) occur?What was the child/ren doing when the injury(ies) occurred?What caused the injury(ies)?Where did the child/ren get medical treatment for the injury(ies)?Do you smoke?YesNoDoes any of the household occupants smoke?YesNoAre you pregnant?YesNoHow often do you smoke?Occasionally (1-2 times per week)DailyHave you recently given birth?YesNoAre you breastfeeding?YesNoDid you ever breastfeed?YesNoHow long did you breastfeed your child/ren?Did you ever smoke during pregnancy?YesNoDid you ever smoke while breastfeeding?YesNoMessageSubmit
