Indicates required field
In what city do you live?
< 1 year
Born and raised
How long have you lived in this area?
(If not native to this area, ask:) Where did you come from?
(If not native to this area, ask:) What brought you here?
Don't ask, indicate the obvious.
In what age-range are you, __-__? (Try to start with an age-range younger than you suspect they are.)
- Use the questions below to have a conversation and discover as many details as indicated.
So, what do you do with all your time these days? (Mark all that apply.)
Don't ask, unless you have to.
If not listed above, fill-in their preferred language below.
Don't ask, unless you have to.
If not listed above, fill-in their ethnic background below.
Child(ren) at home
Teen(s) at home
Grown and gone
Adult Children + Grand Children
High School / GED
What school/college/university did/do you attend? and What year did/will you graduate?
For how long have you been doing that?
(If new to current job, ask:) What other kind of work have you done?
Don't ask, just make your best guess based on your conversation.
Perceived Healthcare Needs
- Talk about each factor listed below to confirm and qualify.
1 = Excellent
2 = Good
3 = Fair
4 = Poor
5 = Critical
How would you rate your over-all health?
Under the care of a doctor
Taking Rx medication
High blood pressure
Mark all that apply.
Do you have any other medical conditions that concern you?
Don't ask, indicate based on your observation.
High stress levels
Not getting enough sleep
Unhealthy food choices
Not getting regular exercise
Limited social support
Which of the following apply to you? (Mark all that apply.)
Is their anything else about your lifestyle that concerns you?
Lower your stress levels
Enhance your social support
Improve your eating habits
Increase your fitness level
Lose some weight
If you had a magic wand, which of the following would you change? (Mark all that apply.)
Is there anything else about your lifestyle that you'd like to change?
Teacher / Coach
Professional (doctor, therapist, lawyer, etc.)
If you needed help with something, to whom would you most likely turn? (Mark all that apply.)
Is there anyone in particular that has been especially helpful to you?
Develop a healthier lifestyle in general
Learn more about disease self-management
Develop better coping skills for managing stress
Fitness training to get regular exercise
Nutrition education for better food choices
Diet and exercise for healthy weight loss
Enhance inter-personal relationships
Which of the following do you feel most ready to tackle? (Skip the item if it's not applicable. Mark all that apply.)
Is there anything else that you feel you're ready to take on as a self-improvement challenge?
Additional Personal Information:
Is there anything going on in your life that could impact a lifestyle change effort at this time? (Such as: a serious medical condition, family issue, financial/legal problem, etc.)
What is ONE thing you would say is unique about YOU?
Could the OptiHealth Research Team notify you regarding local Lifestyle Medicine support services related to your personal health concerns? (Try to get their consent, because this helps support our research and often includes discounts for them, but don't pressure them.)
(If Yes) How would you prefer to be contacted?
(If by email; CONFIRM and ask:) Is this an email address that you check regularly?
(If by phone, CONFIRM, ask:) Do you prefer Voice or Text messages? (Indicate with a V or T and be sure to include the area code.)
Because Exercise is Powerful Medicine and Fitness is the Cure.