Pre-Program Member Wellness Survey Kindly complete this survey before your first Whole Health Coaching Program session, following your Program Consultation with a Care Navigator. 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 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 am able to access the health/wellbeing services that I need when I need them.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) 13. 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) 14. My health and wellness goals are clear to me.(Required) 1 (Strongly Disagree) 2 3 4 5 (Strongly Agree) Dimensions 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.15. 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) 16. 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) 17. 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) 18. 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) Chronic Health Conditions19. From the list below, select all that apply. If none apply, please select "None of the above".(Required) Adrenal Disorders (e.g., Cushing’s syndrome, Addison’s disease) Alzheimer ’s disease Anxiety Disorders Asthma Bipolar Disorder Cardiovascular Diseases Celiac Disease Chronic Back or Body Pain Chronic Fatigue Syndrome (CFS) Chronic Kidney Disease (CKD) Chronic Obstructive Pulmonary Disease (COPD) (e.g., Chronic Bronchitis, Emphysema) Chronic Pain Syndrome Chronic Sinusitis Chronic Urticaria Depression or Mood Disorders Eczema (Atopic Dermatitis) Elevated Cholesterol End-Stage Renal Disease (ESRD) Epilepsy Fibromyalgia Gastroesophageal Reflux Disease (GERD) Heart Disease (including Coronary Artery Disease, Heart Failure, Arrhythmias) Hematologic Cancers (e.g., Leukemia, Lymphoma) Hypertension (High Blood Pressure) Inflammatory Bowel Disease (IBD) (Crohn’s Disease, Ulcerative Colitis) Insomnia Irritable Bowel Syndrome (IBS) Liver Disease (e.g., Cirrhosis, Hepatitis) Lupus Lymphedema Major psychotic/depressive episode in the last year Major Types of Cancer (e.g., Breast, Prostate, Lung, Colorectal, Skin, Pancreatic, Ovarian) Menopause symptoms Metabolic Syndrome Migraine Multiple Sclerosis Obesity Osteoarthritis Osteoporosis Parkinson ’s disease Peripheral Artery Disease Polycystic Ovary Syndrome (PCOS) Post-Traumatic Stress Disorder (PTSD) Prediabetes Psoriasis Restless Leg Syndrome Rheumatoid Arthritis Schizophrenia Sleep Apnea Stroke (Cerebrovascular Disease) Thyroid Disorders (Hypothyroidism, Hyperthyroidism) Type 1 Diabetes Type 2 Diabetes None of the above Other Other Additional Health Information20. Is there any additional information you wish to share?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.21. I consent to the above Confidentiality Notice.(Required) Yes No
