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1. First and Last Name:

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2. Participant I.D

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3. Email Address:

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4. I have a primary health care provider and I am...

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5. If obtaining health insurance was needed, I was able to receive assistance

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6. I have more knowledge surrounding who my primary healthcare provider is

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7. As a result of this program, I have increased/improved my health care with my primary care doctor.

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8. As a result of this program, I am able to communicate better with my primary care doctor.

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9. My understanding of medical information has improved since starting this program.

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10. The device was helpful to me to track my progress and health.

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11. I currently have internet services and was able to complete the Zoom sessions each week

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12. I have reliable, consistent means of transportation?

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

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14. I am able to pay for your utilities each month

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15. What would be considered a normal blood pressure reading?

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16. Carbohydrates can be another way to reference…

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17. Hypertension often refers to…

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

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19. Can you think of one reason why physical activity is so important?

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20. What is your current weight?

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21. In the last 16 weeks have you been diagnosed with any chronic health conditions?  Check all that apply.

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22. During this program I learned new ways to improve my physical fitness.

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

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24. 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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25. As a result of this program, I believe my nutrition habits have improved.

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26. As a result of this program, I feel more confident navigating the grocery store to find healthier food options.

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27. I have gained self-awareness and am able to better assess how certain foods and beverages affect my body in a positive way since starting this program.

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

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29. My ability to read and understand food labels has improved.

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30. The one-on-one sessions with the registered dietician were valuable to me.

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

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32. I understand and can discuss proteins and how to consume them.

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

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

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35. During this program I found the well-being discussions helpful in dealing with my own challenges.

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36. I learned well-being coping strategies in this program that are helping me to develop a healthier lifestyle.

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37. As a result of this program, I would recommend counseling for someone who is trying to lose weight/control diabetes/eat healthier.

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38. The Family Wellness Program provided what was promised.

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39. The material was presented in an organized, understandable fashion.

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40. My overall feeling of health and well-being improved due to the Family Wellness Program.

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41. Please feel free to share any comments or suggestions on your overall experience in the program

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