First Name * Last Name * Local Mailing Address * Email Address * Telephone Number * Gender * Male Female Age * Birth Date * Height * Weight * Student Status * Full Time Part Time Student Status (Year) * 4-year 2-year Questionnaire Section Why are you interested in participating in the Wellness Program? * Why should you be accepted into this program? * What are some personal goals you would like to achieve? * What do you think would be the best thing about being healthy? * What is your motivation? * How can we help achieve your goals? * Confidence Scale Section For the following questions, please use the Confidence Scale to rate each question from 1 to 10. Zero (0) being NOT CONFIDENT and Ten (10) being COMPLETELY CONFIDENT I am confident that I can overcome obstacles that appear in my path * 0 1 2 3 4 5 6 7 8 9 10 I am confident that I can handle anything that comes my way * 0 1 2 3 4 5 6 7 8 9 10 I am confident that I always manage to solve problems if I try hard enough * 0 1 2 3 4 5 6 7 8 9 10 I am confident in the workplace and social settings * 0 1 2 3 4 5 6 7 8 9 10 I am confident dealing with difficult problems and/or people * 0 1 2 3 4 5 6 7 8 9 10 Health History Do you have high blood pressure? * Yes No Do you have high cholesterol? * Yes No Do you have high triglycerides? * Yes No Do you have asthma? * Yes No Do you have diabetes? * Yes No Do you have chronic bronchitis? * Yes No Do you have emphysema? * Yes No Do you have chronic obstructive pulmonary disease? * Yes No Weight Loss History How many weight loss attempts have you tried in the past? * Were you successful at meeting your goal during those attempts? * How serious are you about losing weight and reaching your personal goals? * Time Commitment Confirmation * 0| I understand that the Student Wellness Program requires a daily time commitment. I am aware of my delegated time in the day upon completion of this form.