Coaching Package Application
Health & Wellness Coaching at Sarasota Memorial Health Care System
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
I am...
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A current SMHCS employee
A family member of a current SMHCS employee
A community member
Phone Number
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Email
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example@example.com
Race (self-identified)
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Please Select
American Indian / Alaskan
Asian
Native Hawaiian / Other Pacific Islander
Black / African American
White / Caucasian
Hispanic / Latino
More than one race
Unknown / Opt out
Gender (self-identified)
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Female
Male
Other/Opt out
Do you currently have active cancer?
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Yes
No
Do you currently have, or are in recovery for, an eating disorder?
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Yes
No
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Health & Wellness Coaching Category
This program offers health & wellness coaching in one area of your choosing. Please determine which area you'd most like support in.
What is the MAIN outcome you wish to achieve with health & wellness coaching?
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Nutrition: Learn how to choose the right foods to prevent or improve a health condition (specify which condition below).
Nutrition: Learn how to stop dieting and improve my relationship with food through mindful eating.
Exercise (Beginner): Learn the basics of exercise and create a blueprint for my personal activity goals and preferences.
Exercise (Intermediate to Advanced): Overcome exercise plateaus and re-energize my motivation to exercise.
Stress Management: Learn mindfulness and meditation techniques to manage stress, become more resilient, and improve sleep.
I'm not sure.
Please explain your desired outcome in more detail below:
Why is achieving this outcome important to you?
Which stage of change do you believe you are currently in?
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"I'm aware that a problem exists and I am seriously thinking about overcoming it, but have yet to take action."
"I intend to take action very soon. I need a plan and support to get started."
"I've already started to take action to address my problem. I need support and accountability to continue my progress."
Health Metrics & Medication
Weight (lb)
Height (in)
Blood pressure
Resting heart rate
Please describe your smoking status
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Please Select
Never
Past
Current
If past smoker, when did you quit?
If current smoker, for how long have you smoked?
Do you have a family history of heart disease?
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Yes
No
Do you have Prediabetes (A1c > 5.7%?)
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Yes
No
Do you have Type I Diabetes?
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Yes
No
Do you have Type II Diabetes (A1c > 6.5%?)
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Yes
No
Would you consider yourself overweight or with an elevated BMI?
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Yes
No
Do you have Hypertension (high blood pressure)?
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Yes
No
Do you have high cholesterol?
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Yes
No
Do you have or have you ever been diagnosed with Coronary Artery Disease?
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Yes
No
Do you have or have you ever been diagnosed with Peripheral Vascular Disease?
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Yes
No
Have you ever had a stroke (CVA)?
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Yes
No
Have you ever had a Transient Ischemic Attack (TIA)?
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Yes
No
Do you have or have ever been diagnosed with Heart Failure?
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Yes
No
Have you ever had a Myocardial Infarction (MI, heart attack)?
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Yes
No
If you have had an MI, when was it?
Do you currently, or have you ever been diagnosed with Sleep Apnea?
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Yes
No
List current medications, dosage, and frequency (Put N/A if you do not take any medication)
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Name
Dosage
Frequency
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Lab Work (Optional)
If you've had lab work completed within the past 3 months, please list the values below as they apply.
Date of Lab Test
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Month
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Day
Year
Date
Fasting Blood Glucose (BG) (mg/dL)
A1c (%)
Total Cholesterol (mg/dL)
LDL Cholesterol (mg/dL)
HDL Cholesterol (mg/dL)
Triglycerides (mg/dL)
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