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* 1. Name

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* 2. How did you hear about health coaching?

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* 3. How do you prefer we contact you?

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* 4. Date of Birth

Date of birth

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* 5. Gender

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* 6. Height

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* 7. Weight

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* 8. Race

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* 9. Hispanic

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* 10. Are you limited in any way in any activities because of physical, mental or emotional problems?

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* 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?

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* 12. Type of Disability

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* 13. Refugee Status

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* 14. County of Residence

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* 15. Nebraska county where you prefer to obtain health care

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* 16. Do you have health insurance?

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* 17. Have you had a mammogram in the last 2 years?

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* 18. Have you had a pap test in the last 3 years?

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* 19. Have you been screened for colorectal cancer?

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* 20. Have you ever been told by a health professional that you have high blood pressure?

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* 21. Are you taking any medication for high blood pressure?

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* 22. Have you ever been told by a health professional that you have diabetes?

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* 23. Are you taking any medicine prescribed by your health professional for diabetes?

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* 24. Have you even been told by a doctor, nurse, or other health professional that your blood cholesterol is high?

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* 25. Are you taking any medicine prescribed by your doctor, nurse or other health professional for your high cholesterol?

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* 26. Do you now smoke cigarettes every day, some days or not at all?

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* 27. Do you eat 2 or more servings of fish weekly?

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* 28. Do you eat 3 or more servings of whole grains daily?

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* 29. Do you drink less than 36 ounces of sweetened beverages weekly?

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* 30. Are you currently reducing your sodium or salt intake?

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* 31. How much moderate physical activity do you get in a week?

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* 32. How much vigorous physical activity do you get in a week?

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* 33. How much fruit do you eat in an average day? (1 serving = 1 banana, 1 apple, or a cup of berries)

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* 34. How many vegetables do you eat in a typical day? (1 serving = 12 baby carrots or 1 cup of broccoli)

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* 35. Thinking about your physical health, which includes physical illness and injury, how many days of the past 30 was your health not good?

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* 36. Blood Pressure if you have access to take it.

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