Health Coaching Intake Form Question Title * 1. Name OK Question Title * 2. How did you hear about health coaching? OK Question Title * 3. How do you prefer we contact you? Cell Phone Email Home Phone Work Phone Text OK Question Title * 4. Date of Birth Date of birth Date OK Question Title * 5. Gender Female Male OK Question Title * 6. Height OK Question Title * 7. Weight OK Question Title * 8. Race White Black Asian Native American Pacific Islander Unknown OK Question Title * 9. Hispanic Yes No Known OK Question Title * 10. Are you limited in any way in any activities because of physical, mental or emotional problems? Yes No OK Question Title * 11. Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Yes No OK Question Title * 12. Type of Disability Emotional Intellectual Physical Sensory Mobility OK Question Title * 13. Refugee Status Yes No Unknown OK Question Title * 14. County of Residence OK Question Title * 15. Nebraska county where you prefer to obtain health care OK Question Title * 16. Do you have health insurance? Yes Employer Coverage Yes Health Market Yes Medicare Yes Medicaid Every Woman Matters/Wise Woman No Coverage OK Question Title * 17. Have you had a mammogram in the last 2 years? Yes No I don't know OK Question Title * 18. Have you had a pap test in the last 3 years? Yes No I don't know. OK Question Title * 19. Have you been screened for colorectal cancer? Yes No I don't know OK Question Title * 20. Have you ever been told by a health professional that you have high blood pressure? Yes No I don't know OK Question Title * 21. Are you taking any medication for high blood pressure? Yes No I don't know OK Question Title * 22. Have you ever been told by a health professional that you have diabetes? Yes Type 1 Yes Type 2 Yes Gestational No I don't know OK Question Title * 23. Are you taking any medicine prescribed by your health professional for diabetes? Yes No I don't know OK Question Title * 24. Have you even been told by a doctor, nurse, or other health professional that your blood cholesterol is high? Yes No I don't know OK Question Title * 25. Are you taking any medicine prescribed by your doctor, nurse or other health professional for your high cholesterol? Yes No I don't know OK Question Title * 26. Do you now smoke cigarettes every day, some days or not at all? Not at All Some Days Every Day OK Question Title * 27. Do you eat 2 or more servings of fish weekly? Yes No I don't know OK Question Title * 28. Do you eat 3 or more servings of whole grains daily? Yes No I don't know OK Question Title * 29. Do you drink less than 36 ounces of sweetened beverages weekly? Yes No I don't know OK Question Title * 30. Are you currently reducing your sodium or salt intake? Yes No I don't know OK Question Title * 31. How much moderate physical activity do you get in a week? 30 min. 60 min. 90 min. 150 min. more I don't know OK Question Title * 32. How much vigorous physical activity do you get in a week? 0 30 min. 60 min. 75 min. or more don’t know OK Question Title * 33. How much fruit do you eat in an average day? (1 serving = 1 banana, 1 apple, or a cup of berries) 0 1 2 3 4 5 6 I don't know OK Question Title * 34. How many vegetables do you eat in a typical day? (1 serving = 12 baby carrots or 1 cup of broccoli) 0 1 2 3 4 5 6 or more I don't know OK Question Title * 35. Thinking about your physical health, which includes physical illness and injury, how many days of the past 30 was your health not good? 0 1-5 6-10 11-20 21 or more OK Question Title * 36. Blood Pressure if you have access to take it. Blood Pressure #1 Blood Pressure #2 OK DONE