Coaching Program Questionnaire

Name:*

First Last

Preferred Name:*

Phone Numbers:

Primary:*

Secondary:*

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

E-mail:*

Date of Birth (mm/dd/yyyy):*

Last 4 of SSN:*

Gender:*

Height:

Feet:*

Inches:*

Weight (lbs):

Employer/Organization/Group:*

Current/Relevant Medical Conditions (check all that apply):

Other:*

List the medications, include dosages, that you are currently taking:

How would you rate your overall health? (0 = poor, 2 = fair, 4 = average, 6 = good, 8 = optimal, 10 = thriving)*

Please enter a number from 0 to 10.

Below is a set of statements about various components to the personal program that you are applying for. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. Please read the following questions carefully and circle the answer that best applies. It is important that you are completely honest in your answers. If you are accepted into this program your answers will be referenced by your coach periodically to help gauge your progress within the program.

1. I tend to have a positive outlook.*

2. I am okay with incremental, steady progress.*

3. I am willing to journal/log the food I eat (i.e. food, quantity/servings, calories) consistently every day.*

4. I am willing to develop new nutritional patterns and routines for breakfast, lunch, dinner, snacks, eating out, and social events.*

5. I won’t quit when progress slows but rather I will remain committed to keep plugging forward with unwavering resolve.*

6. I am willing to eat a minimum of five or more servings of vegetables and fruits per day.*

7. I am willing to consistently exercise at least 150 minutes per week.*

8. I am willing to make pure water my primary beverage of choice targeting daily amounts of 74 oz for women or 101 oz for men.*

9. I think it’s possible and I am willing to get a minimum of seven hours of quality sleep per night.*

10. I think that I can sit less, stand more, and move a lot in my daily routines.*

11. I am willing to participate with a personal coach weekly for a minimum of six months in effort to form healthier habits.*

12. I am willing to make lifestyle changes to live healthier even if it means that I have to give up some things that I really enjoy.*

13. Once I make a decision to do something it’s easy for me to stick with it.*

14. I am willing to consume two or fewer sugary and/or artificially sweetened (diet) drinks per week.*

15. I feel supported in my relationships.*

16. I am willing to eat primarily whole foods and eat fewer processed and/or restaurant foods.*

17. In an effort not to overeat I am willing to eat only when I am physically hungry and stop eating when I am satisfied.*

18. I am willing to consistently plan my meals ahead of time.*

19. I think that it’s important for me to positively and proactively manage stress so that I deal with stress in a healthy way.*

20. I understand that my choices can affect my health.*

21. I am willing to communicate with my coach twice a week in between coaching sessions to help me stay engaged and maintain accountability.*

21 Question Sum

21 Question Average

Please read the following questions carefully and indicate the answer that best applies to you.

Have you been on 2 or more diets within the last 12 months?*

Yes
No

Have you lost weight and kept it off within the last year?*

Yes
No

If Yes, how many pounds?*

lbs

How many months have you kept it off?*

months

University of Rhode Island Change Assessment (URICA; modified)

Below is a set of statements about your physical health. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel.

There are five possible responses to each of the items in the questionnaire:

Not At All Like Me
Not Much Like Me
Somewhat Like Me
Mostly Like Me
Very Much Like Me

Choose how closely each of these sentences describe you.

1. It doesn't make much sense for you to consider changing your diet/exercise habits for your health.*

2. You've been thinking that you might want to change something about your diet/exercise habits for your health.*

3. At times, your diet/exercise habits cause health problems and you're determined to change.*

4. It is frustrating, but you feel like you do not have control over your diet/exercise even though you think you do.*

5. Trying to change your diet/exercise habits for your health is pretty much a waste of time for you.*

6. You guess you have faults, but there's nothing you really need to change about your diet/exercise habits or health.*

7. You thought once you had resolved your physical health problems, you would be free of them, but sometimes you still find yourself struggling with them.*

8. You may have a problem with your diet/ exercise habits and health and think you should work on it.*

9. You are really working hard to change your diet/exercise habits for your health.*

10. You hope that someone will give you good advice about your diet/exercise habits and health issues.*

11. Anyone can talk about changing their lifestyle, but you are actually going to do something about it.*

12. After all you've done to try and change your diet/exercise habits and health, every now and then, you still struggle with it.*

URICA Score

How do you think you would benefit from a personal coaching program that emphasizes lifestyle strategies in the areas of nutrition, sleep, exercise and stress management?*

What is your primary reason for applying for this healthy living program?*

Patient Health Questionnaire – 9 (PHQ – 9)
Over the last 2 weeks, how often have you been bothered by any of the following problems (please indicate your answers below)?

Little interest or pleasure in doing things*

Feeling down, depressed or hopeless*

Trouble falling or staying asleep or sleeping too much*

Feeling tired or having little energy*

Poor appetite or overeating*

Feeling bad about yourself—or that you are a failure or have let yourself or your family down*

Trouble concentrating on things, such as reading the newspaper or watching television*

Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual*

Thoughts that you would be better off dead or of hurting yourself in some way*

PHQ-9 Score

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

PHQ-9 Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

Wellbeing Survey
For each of the following questions, select the answer that best describes how you have felt over the last 3 months:

In general, how have you felt about YOURSELF in the past 3 months?*

In general, how have you felt about your HEALTH in the past 3 months?*

For each of the following statements, indicate how you have felt most of the time over the last 3 months:

…I have felt sure about myself*

…I felt liked by others*

…I liked who I am*

…I felt I am successful*

…I felt I have good self-esteem*

…I felt I am satisfied with myself*

…I felt I would not change myself*

…I felt I have a number of good qualities*

…I fell asleep easily*

…I slept through the night*

…I awake rested*

…I felt happy*

…I felt hopeful about the future*

…I felt in control of my life*

…I felt I enjoyed my life*

Wellness Score

Do you receive health insurance through the Employer you listed above?*

Thank you for your interest in the personal coaching program. Please enter your initials to complete this application. Then click "Submit Application".

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