Health Coaching Lifestyle Assessment Survey

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Your answers to the enclosed survey will help your Health Coach to individually tailor this program to help you achieve your health goals. Your answers should be what is actually true for you. When applicable, please indicate how much you agree or disagree with each statement as it applies to you personally.

1.	What is your first name?*

2.	What is your last name?*

3.	What is your current weight (in pounds)?*

4.	What is your height (in inches)?*

5.	Are there any changes to your medical history that you would like your coach to know about? Note: If you are diabetic and have an updated A1C lab value, please list the updated lab value and date.*

Have you had a blood test in the last 12 months with an elevated fasting glucose or A1c value in the pre-diabetic range? Note: Prediabetes is defined as a fasting glucose of 100-125 or an A1c of 5.7-6.4.*

	Yes
	No
	Not Sure
	Not Applicable

7.	What is your A1c lab value? Note: Please indicate Not Applicable.*

8.	What is your fasting glucose lab value? Note: Please indicate Not Applicable. *

10.

On average, how many servings of fruits do you consume daily? (1 serving equals 1 cup or the size of a tennis ball)*

	One or less
	Two Daily
	Three Daily
	Four Daily
	More than Four

11.

How many servings of vegetables do you consume daily? (1 serving equals 1/2 cup cooked, or 1 cup raw)*

	One or Less
	Two Daily
	Three Daily
	Four Daily
	More than Four

12.

How often do you choose whole grains? (Brown rice, whole wheat bread, whole wheat pasta, quinoa, etc...)*

	Eat only whole grains
	Most of the time
	Half of the time
	Sometimes
	Never

13.

How often do you consume sugary beverages or sweets? (soda, juice, packets of sugar, honey, cookies, cakes, granola bars)*

	One or Less Daily
	Two Daily
	Three Daily
	Four Daily
	More Than Four Daily

14.

How often do you eat red meat, high fat dairy products, or fried food?*

	Several times per day
	Once per day
	Several times per week
	Occasionally
	Never

15.

On the average week, how many days a week do you engage in moderate physical activity for 30 minutes or more? (Brisk walk, doubles tennis, dancing, aerobics, breaking a light sweat, able to carry on a conversation)*

	0
	1
	2
	3
	4
	5
	6
	7

16.

On the average week, how many times do you engage in vigorous physical activity for 20 minutes or more? (Running, hiking, singles tennis, fast cycling, heavily sweating, not easily able to carry on a conversation)*

	0
	1
	2
	3
	4
	5
	6
	7

19.	In the average week, how many minutes of combined moderate and vigorous activity are you doing?*

20.

How many hours per day on average do you spend looking at screens (outside of work)?*

	0-1 hours
	1-2 hours
	3-4 hours
	4-6 hours
	5-6 or more hours

21.

If you track steps, about how many steps do you average per day on a typical week?*

	Less than 3000
	3000 to 4999
	5000 to 7999
	8000 to 9999
	10000 to 14999
	15000+
	I don't track

22.	Please describe any barriers to exercise such as injuries or medical conditions:

23.

Do you have a good support network of family and friends?*

	Yes
	No

24.

How often do you feel lonely? *

	Never
	Rarely
	Sometimes
	Often

25.

During the past year have you had any major life or work changes? (Marriage, birth, death, moving, divorce, etc...)*

	Yes
	No

26.

Stress reduction techniques (exercise, meditation, journaling, reading, drawing) are useful in managing stress. How often do you incorporate stress reduction techniques into your week?*

	Daily
	Most Days
	Few Days
	Never

27.

How well do you feel you are coping with your current stress level?*

	Coping very well
	Coping fairly well
	Having trouble coping at times
	Often having trouble coping
	Feeling unable to cope

28.

Do you use any form of tobacco including E-cigarettes? (e.g cigarettes, cigars, chew)*

	Yes
	No, never
	No, quit within the last 3 months
	No, quit more than 3 months ago

29.

How often do you currently use tobacco products?*

	Not Applicable
	Daily
	Less than daily
	Don't know

30.	What is the average number of cigarettes you smoke in a day? Enter N/A if not applicable*

31.

How often do you get 7-8 hours of sleep per night?*

	Most of the time
	Less than half of the time
	Ocassionally
	Never

32.

How many hours of sleep do you usually get at night?*

	5 hours or less
	6 hours
	7 hours
	8 hours
	9 hours or more

33.

Do you feel rested when you wake up in the morning?*

	Yes, all of the time
	Most of the time
	Sometimes
	Never

34.	Do you have any current problems relating to sleep? If so, what are your main concerns?

35.

When all is said and done, I am the person who is responsible for taking care of my health. *

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

36.

Taking an active role in my own health care is the most important thing that affects my health.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

37.

I know what each of my prescribed medications do.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

38.

I am confident I can tell whether I need to go the doctor or whether I can take care of a health problem myself.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

39.

I am confident I can tell a doctor concerns I have, even when he or she does not ask.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

40.

I am confident I can follow through on medical treatments I may need to do at home. *

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

41.

I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

42.

I know how to prevent further problems with my health.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

43.

I am confident I can figure out solutions when new problems arise with my health.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

44.

I am confident I can maintain lifestyle changes, like eating right and exercising even during times of stress.*

	Disagree Strongly
	Disagree
	Agree
	Agree Strongly
	Not Applicable

45.	What goals would you like to achieve within the next 3-6 months?*

46.	Are there any specific barriers to meeting your goals? *

47.	What are some of your personal strengths that can help you to achieve your goals?*

48.	What does your support system look like right now? (i.e. spouse or partner, family members, or friends who encourage and support you in making healthy changes)*

49.

Have you reviewed the program coaching agreement (this would have been emailed to you with this survey link)? Note: Select “N/A” if you are closing out of the program. *
As a reminder, the agreement helps to define the partnership between you and your coach. As a Providence Health Plan member, you are eligible to receive telephonic or virtual lifestyle coaching at no cost to you. Your participation in the coaching program is voluntary and you can decide to opt out at any time. The coaching process is a collaborative relationship and those who are most successful are taking time to prepare for sessions. Coaching is not a substitute for mental health treatment, nutrition counseling, or medical treatment. Program duration can vary see the coaching agreement for more detail. If you have questions about the agreement, please ask your coach during your next scheduled coaching session.

	Yes
	No
	N/A