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1. First and Last Name:

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2. Email Address:

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

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4. I have a primary healthcare provider.

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5. I see my primary health care provider regularly.

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

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7. I am able to communicate with my primary care provider.

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8. I currently have a good understanding of medical information.

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

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

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11. Carbohydrates can be another way to reference…

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12. Hypertension often refers to…

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

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

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15. What is your current weight?

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

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

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18. I am aware of ways to improve my physical fitness.

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

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20. 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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21. Regarding my nutritional habits, I am...

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

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

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

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

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

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

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29. I am able to read and understand food labels

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

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

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

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

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34. I can easily access information I need to improve my health

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35. Outside of this program, I can access education I need to improve my health

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36. The activities I will learn in the family wellness program are important to me

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37. I am able to make my choices in how I engage in the activities I plan on learning in the family wellness program

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38. I plan to continue using the activities I will learn in the family wellness program after the program has ended

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39. What is something you are really hoping to learn more about during this session?  (Select all that apply)

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

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

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