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* 1. First and Last Name:

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* 2. D/O/B:

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* 3. Email Address:

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* 4. Phone Number [ex. (area code)-123-4567]:

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* 5. Do you live in Detroit?

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* 6. Address

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* 7. How many family members, including yourself, do you currently live with?

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* 8. How would you describe your ethnic group? (select all that apply)

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* 9. Please specify your gender 

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* 10. What is the highest level of school that you have finished? 

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* 11. What is your household income? 

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* 12. What is your current work situation? 

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* 13. Do you participate in any of the following programs? [Select all that apply] 

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* 14. How did you hear about the program? 

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* 15. Select your preferred Brilliant Detroit Neighborhood Hub

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* 16. If I need help obtaining health insurance, I am aware of how to gain assistance.

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* 17. I have a primary healthcare provider.

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* 18. I see my primary health care provider regularly.

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* 19. I am able to actively improve my health care with my primary care provider.

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* 20. I am able to communicate with my primary care provider.

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* 21. I currently have a good understanding of medical information.

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* 22. I currently have internet services and I am able to complete the Zoom sessions each week.

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* 23. I have reliable, consistent means of transportation?

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* 24. I am able to purchase adequate groceries and household supplies each month

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* 25. I am able to pay for my utilities each month.

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* 26. What would be considered a normal blood pressure reading?

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* 27. Carbohydrates can be another way to reference…

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* 28. Hypertension often refers to…

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* 29. What is the recommended number of minutes of physical activity needed per week?

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* 30. What is your current weight?

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* 31. What is your weight GOAL?  (Example: lose 10 pounds by the end of 16 weeks)

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* 32. Have you been diagnosed with any chronic health conditions?  Check all that apply.

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* 33. I am aware of ways to improve my physical fitness.

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* 34. How many minutes of physical activity do you currently get per week?

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* 35. In the last 30 days, how many days per week do you participate in intentional exercise such as walking fast, jogging, dancing, swimming, biking, or other similar activities that increased your heart rate?

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* 36. Regarding my nutritional habits, I am...

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* 37. I feel confident navigating the grocery store to find healthier food options.

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* 38. I have self-awareness and am able to assess how certain foods and beverages affect my body in a positive way.

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* 39. I understand and can discuss healthy grains and how to consume them.

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* 40. I understand and can discuss healthy fats and how to consume them.

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* 41. I understand and can discuss proteins and how to consume them.

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* 42. In the last 30 days, on average, how many times a day did you eat fruit?

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* 43. In the last 30 days, on average, how many times a day did you eat vegetables?

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* 44. I am able to read and understand food labels

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* 45. I currently am able to receive one-on-one sessions with a registered dietician. 

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* 46. In the past I have found well-being discussions helpful in dealing with challenges.

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* 47. I am aware of well-being coping strategies that can help me to develop a healthier lifestyle.

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* 48. I would recommend counseling for someone who is trying to lose weight/control diabetes/eat healthier.

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* 49. What are some ways in which FWP staff can further assist you in relation to your personal goals?

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* 50. In your own words, describe what you would like to obtain from participating in the program?

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