Rubenfire Family Wellness Program Registration/ Pre-Survey Question Title * 1. First and Last Name: Question Title * 2. D/O/B: Question Title * 3. Email Address: Question Title * 4. Phone Number [ex. (area code)-123-4567]: Question Title * 5. Do you live in Detroit? Yes No Question Title * 6. Address Address Address 2 City/Town State/Province ZIP/Postal Code Question Title * 7. How many family members, including yourself, do you currently live with? Question Title * 8. How would you describe your ethnic group? (select all that apply) White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or another Pacific Islander Biracial/ Multiracial Question Title * 9. Please specify your gender male female nonbinary prefer not to answer Question Title * 10. What is the highest level of school that you have finished? Completed 4 years of college or more. Completed 2 years of college. Completed some college. High school diploma or GED Less than a high school degree Question Title * 11. What is your household income? Under $15,000 Between $15,000 and $29,999 Between $30,000 and $49,999 Between $50,000 and $74,999 Between $75,000 and $99,999 Between $100,000 and $150,000 Over $150,000 Question Title * 12. What is your current work situation? Employed (full time) Employed (part time) Contract/ Seasonal/ Temporary Self-employed. Unemployed Retired Question Title * 13. Do you participate in any of the following programs? [Select all that apply] SNAP/Food Benefits (Supplemental Nutrition Assistance Program) FAP (Food Assistance Program) WIC Head start/Early Head start Energy Assistance Other Question Title * 14. How did you hear about the program? Social Media Brilliant Detroit Authority Health Referral Previous / current participant Question Title * 15. Select your preferred Brilliant Detroit Neighborhood Hub I am not affiliated with a Brilliant Detroit Hub Spring wells Brilliant Site: 9104 Rathbone, Detroit, MI 48209 Southwest Site: 5675 Larkins St, Detroit, MI 48210 Osborn Brilliant Site: 13800 Eastburn Street, Detroit, MI 48205 Morningside Brilliant Site: 5048 Balfour Rd., Detroit MI 48224 Martin Park Brilliant Site: 16587 La Salle Ave Detroit, MI 48221 Littlefield - 12789 Indiana Ave, Detroit, MI 48238 Fitzgerald Brilliant Site: 16919 Prairie, Detroit, MI 48221 Dexter-Linwood Brilliant Site: 2634 Webb, Detroit, MI 48206 Cody Rouge Brilliant Site: 7425 Fielding, Detroit, MI 48228 Chandler Park - 5312 Newport, Detroit, MI 48213 Central Detroit Brilliant Site: 803 Hazelwood, Detroit, MI 48202 Brightmoor Brilliant Site: 15509 Heyden, Detroit, MI 48223 Question Title * 16. If I need help obtaining health insurance, I am aware of how to gain assistance. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 17. I have a primary healthcare provider. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 18. I see my primary health care provider regularly. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 19. I am able to actively improve my health care with my primary care provider. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 20. I am able to communicate with my primary care provider. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 21. I currently have a good understanding of medical information. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 22. I currently have internet services and I am able to complete the Zoom sessions each week. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 23. I have reliable, consistent means of transportation? Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 24. I am able to purchase adequate groceries and household supplies each month Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied Question Title * 25. I am able to pay for my utilities each month. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 26. What would be considered a normal blood pressure reading? 130/80 120/80 110/88 100/80 Question Title * 27. Carbohydrates can be another way to reference… Beans and seeds Protein Grains Whey Question Title * 28. Hypertension often refers to… High cholesterol High Blood pressure Liver Disease Diabetes Question Title * 29. What is the recommended number of minutes of physical activity needed per week? 130 minutes per week 125 minutes per week 150 minutes per week 250 minutes per week Question Title * 30. What is your current weight? Question Title * 31. What is your weight GOAL? (Example: lose 10 pounds by the end of 16 weeks) Question Title * 32. Have you been diagnosed with any chronic health conditions? Check all that apply. Hypertension/High Blood Pressure Diabetes Musculoskeletal Conditions Other Question Title * 33. I am aware of ways to improve my physical fitness. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 34. How many minutes of physical activity do you currently get per week? 0-30 minutes per week 30-60 minutes per week 60-90 minutes per week 90-120 minutes per week 120-150 minutes per week More than 150 minutes per week Question Title * 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? 0 days per week 1 day per week 2 days per week 3 days per week 4 days per week 5+ days per week on average Question Title * 36. Regarding my nutritional habits, I am... Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied Question Title * 37. I feel confident navigating the grocery store to find healthier food options. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 38. I have self-awareness and am able to assess how certain foods and beverages affect my body in a positive way. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 39. I understand and can discuss healthy grains and how to consume them. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 40. I understand and can discuss healthy fats and how to consume them. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 41. I understand and can discuss proteins and how to consume them. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 42. In the last 30 days, on average, how many times a day did you eat fruit? 0 servings per day 1-2servings per day 3-4 servings per day 5 or more servings per day Question Title * 43. In the last 30 days, on average, how many times a day did you eat vegetables? 0 servings per day 1-2 servings per day 3-4 servings per day 5+ servings per day Question Title * 44. I am able to read and understand food labels Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 45. I currently am able to receive one-on-one sessions with a registered dietician. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 46. In the past I have found well-being discussions helpful in dealing with challenges. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 47. I am aware of well-being coping strategies that can help me to develop a healthier lifestyle. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 48. I would recommend counseling for someone who is trying to lose weight/control diabetes/eat healthier. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 49. What are some ways in which FWP staff can further assist you in relation to your personal goals? Obtaining a primary healthcare provider Referrals Registered dietitian sessions / meal planning Fitness sessions Other (please specify) Question Title * 50. In your own words, describe what you would like to obtain from participating in the program? Done