Veteran Wellness Network Health Assessment
A confidential health and wellness assessment for veterans. Your responses help us support your well-being with respect, trust, and professionalism. Special Service Appreciation Benefit for all Veterans, Their Spouses and First Responders.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Branch of Military Service
*
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Other
Years of Service
*
Current Status
*
Active Duty
Veteran
Retired
Reserve/Guard
Spouse/Dependent
Caregiver
VA Staff
Other
Health & Wellness Information
On a scale from 1-5 with 1 being the worst and 5 being the best how would you rate your current overall health?
How would you describe your overall health?
How much do you currently weigh?
What is your height?
What is your age?
What is your gender?
Are you interested in losing weight? If so approximately how many pounds?
What is your ideal weight and health goals?
How many days per week do you engage in physical activity?
How many hours of sleep do you typically get per night?
How many meals do you eat per day?
On a scale from 1-10 how committed are you to getting to your health goals?
Support and Follow-Up
Preferred method of contact
Phone
Email
Text/SMS
Other
Is there anything else you would like us to know or any specific goals you have for your health and wellness?
Submit Assessment
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