Healthy Lifestyle Registration Form

Healthy Lifestyles Registration Form

Use this form to register for the Be Well Healthy Lifestyle Program starting on Feb. 14 - Mar. 20 from 2:30pm - 3:30pm
This is an evidence-based 6-week program focusing on the 8 Dimensions of wellness. In the lunch and learn style sessions, participants will learn about the recommendations for different areas of health and wellness. Participants will then set and meet individual goals based on the recommendations and their current level of activity. Over the course of the program, participants will work to apply their goals and the recommendations as part of their daily lifestyle.

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Name*
First Last
Email*
Enter Email Confirm Email
Do you have a pedometer that you can use to track your physical activity levels?*
- Yes
- No
Ex: Fitbit, Garmin, smart phone with an activity tracking app, etc.

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This section will be dedicated to the program pre-survey. The information that you provide will be used to show the impact of the program in comparison with data collected at the end of the program.
I am confident I can have a positive effect on my health.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I have set some definite goals to improve my health.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I have been able to meet the goals I set for myself to improve my health.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am actively working to improve my health.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I try to be physically active most days of the week.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am confident I can fit physical activity into the busiest of days.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am confident to look for opportunities throughout the day to be physically active.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am confident I can find ways to take breaks from sitting while still being productive at work.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am confident I can order healthy options off restaurant menus.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.
I am confident that I know how to plan healthy meals.*
Please enter a number from 1 to 5.
On a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), how accurate is this statement in describing your current state. Please enter a number from 1 to 5 to answer.

Be Well

Healthy Lifestyles Registration Form

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