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Mission Meltaway

Broome County Office for Aging
Mission Meltaway: Lose “12” in 2012

Participant Registration Form

Full Name: *

Preferred Name:

The name you prefer to be addressed by such as a nick name of short name. You may leave this line blank if your Full name is your preferred name.

Address: *

Street Address

City: *

State: *

Zip Code: *

Phone: *

A phone number where you can be reached.

Email: *

Email address where you can be reached.

DOB: *

Date of Birth

Gender: *

Height: *

Weight: *

Partner:

What is your Mission Meltaway partner's name?

Center: *

Which Senior Center will you visit for Mission Meltaway?

Mission Meltaway Pre-Survey

Health Questionnaire
Please use the following scale to rate how satisfied you feel now about different aspects of your daily life. Choose any number from this list (1 to 9), and indicate your choice on the questions below.

1 = Extremely Dissatisfied
2 = Very Dissatisfied
3 = Moderately Dissatisfied
4 = Somewhat Dissatisfied
5 = Neutral
6 = Somewhat Satisfied
7 = Moderately Satisfied
8 = Very Satisfied
9 = Extremely Satisfied

mood:

Mood (feelings of sadness, worry, happiness, etc.)

Self-esteem:

Energy and feeling healthy:

Health problems (diabetes, high blood pressure, etc.):

General appearance:

Leisure and recreational activities:

Physical mobility and physical activity:

Eating habits:

Body image:

Overall Quality of Life:

Weight Loss Readiness: Motivation

Please use the following scale to rate how motivated you feel now. Choose any number from this list (0 to 4), and indicate your choice on the questions below.
0 = Not at all motivated
1 = Slightly motivated
2 = Somewhat motivated
3 = Quite motivated
4 = Extremely motivated

Compared to previous attempts, how motivated are you to lose weight this time?:

Compared to previous attempts, how motivated are you to change your eating habits this time?:

Compared to previous attempts, how motivated are you to increase your physical activity this time?:

How motivated are you to stay committed to a weight loss program for the time it will take to reach your weight loss goal?:

How motivated are you to try new strategies/techniques for changing your eating, exercise, and other behaviors?:

Weight Loss Readiness: Expectations

Please use the following scale to rate how realistic the statement is now. Choose any number from this list (0 to 4), and indicate your choice on the questions below.

Figuring a weight loss of one to two pounds per week, how realistic is your expectation?:

Think honestly about how much weight you hope to lose and how quickly you hope to lost it.

How satisfied would you be if you achieved a 10% weight loss?:

If you achieved a 10% weight loss that significantly improved your health, how satisfied would you be?:

If you achieved a 10% weight loss that significantly improved your quality of life, how satisfied would you be?:

Nutrition Questionaire

How many servings of fruit do you usually eat every day?:

0 Servings

1 Serving

2 Servings

3 or more Servings

(1 serving = 1 piece; ½ cup chopped cooked, or canned fruit, or ¾ cup of juice)

How many servings of vegetables do you usually eat every day?:

0 Servings

1 Servings

2 Servings

3 or more Servings

(1 serving = 1 cup raw leafy greens; ½ cup cooked or raw vegetables; or ¾ cup juice)

How many servings of whole grains or high fiber foods do you usually eat every day? :

0 Servings

1 Servings

2 Servings

3 or more Servings

(such as breakfast cereals like bran flakes or oatmeal, whole wheat breads, whole grain crackers, beans, brown rice)

How many servings of milk, cheese, yogurt, or calcium rich soy products do you usually eat every day?:

0 Servings

1 Servings

2 Servings

3 or more Servings

(1 serving = 1 cup or 8 ounces of milk or yogurt; or 1 slice of cheese)

How many glasses of non-alcoholic fluids, including water, do you usually drink every day? :

(1 glass = 1 cup or 8 ounces)

Are you knowledge about appropriate food portion sizes?:

Yes

Do you typically eat appropriate food portion sizes?:

Yes

Do you record your food intake on a daily basis?:

Yes

Physical Activity Questionnaire

Physical activity includes activities such as walking, biking, or other exercise which you do to improve your health. Regular physical activity means physical activity at least three times each week for at least 20 minutes each time.

Mark the statement which best describes you?:

I have been doing regular physical activity for more than six months.

I have been doing regular physical activity, but for less than six months.

I am not doing regular physical activity, but I intend to begin regular physical activity in the next 30 days.

I am not doing regular physical activity, but I intend to begin doing regular physical activity in the next six months.

I am not doing regular physical activity, and I do not intend to begin doing regular physical activity in the next six months.

How far or how long do you normally walk each day? :

Do you use a step counter (pedometer) to track your steps? :

Yes

Do you record your physical activity on a daily basis? :

Yes

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Mission Meltaway

Broome County Office for Aging
Mission Meltaway: Lose “12” in 2012

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Broome County, NY

Mission Meltaway

Broome County Office for Aging Mission Meltaway: Lose “12” in 2012

Copyright

Quick Links

Broome Online

Broome County Office for Aging
Mission Meltaway: Lose “12” in 2012