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Pre-Program Member Wellness Survey

Kindly complete this survey before the Program Consultation with your Whole Health Coach.

Member Information

1. Age(Required)
2. Gender

Wellness Status

Please 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)
6. I can confidently identify and access the appropriate health/wellbeing services that I need when I need them.(Required)
7. I can develop a wellness vision supported by my strengths and values.(Required)
8. I manage health challenges effectively.(Required)
9. My ideal level of wellness is clear to me.(Required)
10. I have a sound understanding of the interconnectedness of the mind and body.(Required)
11. I am aware of what I need to live a healthy, balanced life.(Required)
12. I have a clear understanding of how the structures (people, resources, systems, and environment) in my life contribute to my wellbeing.(Required)
13. My health and wellness goals are clear to me.(Required)
14. I feel content with the balance between my work, family, friends, and self.(Required)
15. I spend my free time thoughtfully.(Required)
16. I value my overall health and wellbeing.(Required)
17. I am aware of my risk factors for disease.(Required)
18. I am able to access dental care when I need it.(Required)
19. I am able to access reliable transportation to/from healthcare appointments.(Required)
20. I am able to take sufficient time away from work to attend healthcare appointments as needed.(Required)

Dimensions of Wellness

For each area below, write a number between 1 (low) and 5 (high) that best represents where you are and where you want to be.
21. Beliefs. My emotional thoughts and feelings, attitudes and behaviors, self-fulfilling prophecies, and accepting accountability. | Where I am at now.(Required)
Beliefs. My emotional thoughts and feelings, attitudes and behaviors, self-fulfilling prophecies, and accepting accountability. | Where I want to be.(Required)
22. Community: My social connections, relationships, senses of belonging, support network. | Where I am at now.(Required)
Community: My social connections, relationships, senses of belonging, support network. | Where I want to be.(Required)
23. Environment: Our Surroundings - indoors and out. Where I live, learn, work, play and worship. | Where I am at now.(Required)
Environment: Our Surroundings - indoors and out. Where I live, learn, work, play and worship. | Where I want to be.(Required)
24. Nourishment: How I fuel my body, manage my diet, and my relationship with food and drink. | Where I am at now.(Required)
Nourishment: How I fuel my body, manage my diet, and my relationship with food and drink. | Where I want to be.(Required)
25. Physical Activity: I engage in regular movement and exercise. | Where I am at now.(Required)
Physical Activity: I engage in regular movement and exercise. | Where I want to be.(Required)

Additional Health Information

Confidentiality Notice Acknowledgement

The 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.
27. I consent to the above Confidentiality Notice.(Required)