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 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 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 am able to access the health/wellbeing services that I need when I need them.(Required)
13. I have a clear understanding of how the structures (people, resources, systems, and environment) in my life contribute to my wellbeing.(Required)
14. My health and wellness goals are clear to me.(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.
15. 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)
16. 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)
17. 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)
18. 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)

Chronic Health Conditions

23. From the list below, select all that apply. If none apply, please select "None of the above".(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.
25. I consent to the above Confidentiality Notice.(Required)