Mid-Program Member Wellness Survey Kindly complete this survey before your fourth Whole Health Coaching Program session. Member InformationFirst name(Required)Last Name(Required)Date of Birth(Required)Preferred Email Address(Required)1. Age(Required) 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 or over 2. Gender Male Female Non-binary Transgender Other 3. Home Zip Code(Required)4. Work Zip Code(Required)Wellness StatusPlease rate the following statements on a scale from 1 - 5, with 1=Strongly Disagree, 2=Disagree, 3=Undecided, 4=Agree, 5=Strongly Agree.5. I am confident in my ability to make healthy changes in my life.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 6. I can confidently identify and access the appropriate health/wellbeing services that I need when I need them.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 7. I can develop a wellness vision supported by my strengths and values.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 8. I manage health challenges effectively.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 9. My ideal level of wellness is clear to me.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 10. I have a sound understanding of the interconnectedness of the mind and body.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 11. I am aware of what I need to live a healthy, balanced life.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 12. I have a clear understanding of how the structures (people, resources, systems, and environment) in my life contribute to my wellbeing.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 13. My health and wellness goals are clear to me.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 14. I feel content with the balance between my work, family, friends, and self.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 15. I spend my free time thoughtfully.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 16. I value my overall health and wellbeing.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 17. I am aware of my risk factors for disease.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 18. I am participating/I participated in the Metabolic Reset Program.(Required) Yes No 19. Please select areas of improvement since beginning the program.(Required) Chronic pain (e.g., back pain, neck pain) Stress or anxiety Insomnia or sleep disturbances Headaches or migraines Digestive issues (e.g., bloating, constipation) Fatigue or low energy Menstrual irregularities or menstrual pain Allergies or sinus issues Joint pain or arthritis Emotional imbalances (e.g., depression, irritability) None 20. Did you begin taking herbal supplements during the program?(Required) Yes No 21. If "Yes", please list the name(s) of the supplements:Dosage: For What Condition:22. On a scale of 0 to 10, how well do you understand the ways in which acupuncture supports your overall wellness, with 0 being "Not at all" and 10 being "Extremely well"?(Required)01234567891023. Please rate your current stress level with 0 being “Calm” and 10 being “Extremely stressed”.(Required)01234567891024. On a scale of 0 to 10, please rate your confidence in managing your stress, from 0 being “Not at all confident” to “Extremely confident.”(Required)012345678910Dimensions of WellnessFor each area below, write a number between 1 (low) and 5 (high) that best represents where you are and where you want to be.25. Beliefs. My emotional thoughts and feelings, attitudes and behaviors, self-fulfilling prophecies, and accepting accountability. | Where I am at now.(Required) 1 (Low) 2 3 4 5 (High) Beliefs. My emotional thoughts and feelings, attitudes and behaviors, self-fulfilling prophecies, and accepting accountability. | Where I want to be.(Required) 1 (Low) 2 3 4 5 (High) 26. Community: My social connections, relationships, senses of belonging, support network. | Where I am at now.(Required) 1 (Low) 2 3 4 5 (High) Community: My social connections, relationships, senses of belonging, support network. | Where I want to be.(Required) 1 (Low) 2 3 4 5 (High) 27. Environment: Our Surroundings - indoors and out. Where I live, learn, work, play and worship. | Where I am at now.(Required) 1 (Low) 2 3 4 5 (High) Environment: Our Surroundings - indoors and out. Where I live, learn, work, play and worship. | Where I want to be.(Required) 1 (Low) 2 3 4 5 (High) 28. Nourishment: How I fuel my body, manage my diet, and my relationship with food and drink. | Where I am at now.(Required) 1 (Low) 2 3 4 5 (High) Nourishment: How I fuel my body, manage my diet, and my relationship with food and drink. | Where I want to be.(Required) 1 (Low) 2 3 4 5 (High) 29. Physical Activity: I engage in regular movement and exercise. | Where I am at now.(Required) 1 (Low) 2 3 4 5 (High) Physical Activity: I engage in regular movement and exercise. | Where I want to be.(Required) 1 (Low) 2 3 4 5 (High) Additional Health Information30. Is there any additional information you wish to share?31. Sharing your success in our program with other VEBA members is a wonderful way to ensure that others understand, participate, and benefit from Whole Health Coaching. Please let us know if you are interested in sharing your experience by selecting 'Yes' or 'No' below to connect with a VEBA team member and multiply your success by sharing your story.(Required) Yes! Please reach out to me. No, thank you. Confidentiality Notice AcknowledgementThe information provided in this form contains protected health information (PHI) protected by federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically and use encryption and access controls to safeguard your PHI during transmission and storage. By submitting this form, you acknowledge the collection and use of your PHI as outlined in the Notice of Privacy Policy.32. I consent to the above Confidentiality Notice.(Required) Yes No
