FWP Pre Survey-MAY 2023 Cohort 2
1.
First and Last Name:
2.
Email Address:
3.
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
4.
I have a primary healthcare provider.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
5.
I see my primary health care provider regularly.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
6.
I am able to actively improve my health care with my primary care provider.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
7.
I am able to communicate with my primary care provider.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
8.
I currently have a good understanding of medical information.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
9.
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
10.
I have reliable, consistent means of transportation?
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
11.
I am able to purchase adequate groceries and household supplies each month
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
12.
I am able to pay for my utilities each month.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
13.
What would be considered a normal blood pressure reading?
130/80
120/80
110/88
100/80
14.
Carbohydrates can be another way to reference…
Beans and seeds
Protein
Grains
Whey
15.
Hypertension often refers to…
High cholesterol
High Blood pressure
Liver Disease
Diabetes
16.
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
17.
Can you think of one reason why physical activity is so important?
18.
What is your current weight?
19.
What is your weight GOAL? (Example: lose 10 pounds by the end of 16 weeks)
20.
Have you been diagnosed with any chronic health conditions? Check all that apply.
Hypertension/High Blood Pressure
Diabetes
Musculoskeletal Conditions
Other
21.
I am aware of ways to improve my physical fitness.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
22.
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
23.
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
24.
Regarding my nutritional habits, I am...
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
25.
I feel confident navigating the grocery store to find healthier food options.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
26.
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
27.
I understand and can discuss healthy grains and how to consume them.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
28.
I understand and can discuss healthy fats and how to consume them.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
29.
I understand and can discuss proteins and how to consume them.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
30.
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
31.
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
32.
I am able to read and understand food labels
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
33.
I currently am able to receive one-on-one sessions with a registered dietician.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
34.
In the past I have found well-being discussions helpful in dealing with challenges.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
35.
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
36.
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
37.
What is something you are really hoping to learn more about during this session? (Select all that apply)
Understanding food labels
Calorie counting
Increasing/ maintaining physical activity
Adopting new behavioral changes
Becoming more aware of my thoughts and decisions.
Other (please specify)
38.
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 dietician / meal planning
Fitness sessions
Other (please specify)
39.
In your own words, describe what you would like to obtain from participating in the program?