Lifestyle Change Award Nomination
Sponsored by: Molina Healthcare
Form
Your name
First Name
Last Name
Your email address
example@example.com
Your phone number
Please enter a valid phone number.
Nominee's name
First Name
Last Name
Is this a self nomination?
Yes
No
Does the nominee know they are being nominated?
Yes
No
Picture of nominee
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What type of lifestyle change has this person made?
Increased physical activity
Adopted healthier eating habits/weight loss plan
Stopped smoking or vaping
Managed blood pressure, cholesterol or blood sugar
Learned family's heart/brain history and risk factors
Other
Please describe why this person deserves recognition for their lifestyle change.
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