Enrollment Form – HealthyWayzz LLC

Email*

First Name*

Last Name*

What would you prefer to be called ?

Address*

City*

State*

Zip Code *

Preferred Phone Number *

What Number Is This ?

What is your date of birth?*

Ethnicity: Are you Hispanic/Latino? *

What is your race? (Please check all that apply.)*

What is your gender? *

Do you have a disability or impairment?

Who is your primary care physician? *

How did you hear about this program? (Please be specific.)

Were you referred to this program by a physician? If so, who?

Do you have any health issues your coach should be aware of?

What is your education level?

What is your current height?*

What is your current weight?*

Have you received blood work in the past 12 months indicating that you are are risk for type 2 diabetes (prediabetes)?*

If you completed the CDC Diabetes Risk Test, what was your score? *

Have you ever been diagnosed with gestational diabetes (diabetes during a pregnancy)?

Are you currently pregnant?

Have you ever been diagnosed with high blood pressure?*

Do you have a mother, father, sister, or brother with diabetes?*

Are you physically active?**

Have you ever had a previous diagnosis of type 1 or type 2 diabetes?

Yes

No

How confident are you in your readiness to change your eating habits?

How confident are you in your readiness to change your level of physical activity?

If you are participating in a virtual program, are you comfortable emailing your coach with your current weight prior to each meeting?

If you answered “No” or “Maybe” to the question above, please provide more information.

What are you hoping to gain by participating in this program?

Is there anything else that it would be helpful for your coach to know or that you would like to share? Any specific coaching style you are looking for, specific goals you have for yourself…