Franklin Member Lifestyle Assessment
Fill out the questions that reflects your age and health status best
Numbering is based on 1 least to highest number 5 is most
1 is always the least favorable to your health and the highest number 5 is the most favorable to your health.
First Name
Your answer
Last Name *
Your answer
Email Address *
Your answer
Gender *
My Approximate waist line is
Your answer
My approximate weight is
Your answer
My approximate height in ft.
Inches added to feet to equal total height
I complete an annual wellness exam with a PCP.
The medical provider who does your annual exam and the providers location by city of state
Your answer
Education - Highest Level *
Age
MM
/
DD
/
YYYY
Do you have Health Insurance?
The name of my insurance
Your answer
Name of Employer if company is providing insurance
Your answer
I am interested in learning about genetics related to my health.
What is your favorite exercise?
How much time do you spend on the computer, smartphone, or TV (unrelated to work)?
Section: Physical Activity
I engage in sweat producing physical activity for 20-30 minutes at least three times per week
Almost never
Almost always
My physical activity includes stretching, aerobic activity and strength conditioning
Almost Never
Almost Always
I use a wearable fitness device (ie, Fitbit)
Almost Never
Almost Always
Many of my friends use a wearable fitness device (ie, Fitbit)
Almost None
Almost All
Section: Nutrition
I eat a well balanced diet
Almost Never
Almost Alsways
I avoid eating at fast food restaurants
Almost Never
Almost Always
My weight is within the recommendations for my height and gender
No
Yes
I include organic foods in my grocery shopping
No
Yes
I cook and eat with my family
Not Very Often
Very Often
Section: Self Care
I regularly get 7 to 8 hours of restful sleep
Almost Never
Almost Always
I avoid the use of tobacco products (cigarettes, smokeless tobacco, eCigs, cigars, pipes)
Almost Never
Almost Always
I protect my skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sun lamps.
No
Yes
I know my health numbers & maintain them within normal limits. (blood type, blood pressure, BMI, cholesterol, height, weight) *
No
Yes
I practice good dental hygiene.
No
Yes
I limit the amount of alcohol I intake
Almost Never
Almost Always
Section: Social and Environmental Wellness
I take time to socialize with my family and friends.
No
Yes
I contribute time and/or money to at least one organization that strives to better the community where I live.
no
yes
I use social media to keep up with friends, family, and current events.
Way to much
The Right Amount
My relationships and behaviors are maintained in a manner that is healthy for me and for others.
No
Yes
I am able to develop close intimate, personal relationships.
No
Yes
I feel positive about myself.
Almost Never
Almost Always
Section: Emotional Management
I express my feelings of anger in ways that are not hurtful to others.
Almost Always
Almost Never
I set realistic objectives for myself.
Almost Never
Almost Always
When I make mistakes, I learn from them.
Almost Never
Almost Always
I feel unreasonably hurried in my daily routine.
Almost Always
Almost Never
I accept responsibility for my own actions.
Almost Never
Almost Always
Section: Intellectual Wellness
I seek opportunities to learn new things.
Seldom
Often
Before making decisions, I gather facts.
No
Yes
Section: Occupational Wellness
I enjoy my work.
Almost Never
Almost Always
I am satisfied with the balance between my work time and leisure time.
Almost Never
Almost Always
I am satisfied with my ability to manage and control my workload.
Almost Never
Almost Always
At work my level of authority is consistent with my level of responsibility.
No
Yes
Section: Spirituality and Values
I feel that my life has a positive purpose.
Seldom
Most Of The Time
My leisure time activities are consistent with my values.
No
Yes
My actions are guided by my own beliefs, rather than the beliefs of others.
No
Yes
I spend a portion of every day in prayer, meditation, and/or personal reflection.
Almost Never
Almost Always
Data Use Policy *
Franklin IPS, LLC (Franklin Wellness) values you as a patient and respects the privacy of your personal and medical information that is disclosed to us in the course of our treatment relationship with you. Your personal and medical information is the information that is required when you sign up for wellness serivces and that is collected during your relationship with Franklin Wellness. Your information will be used exclusively for membership in the Healthy Community and as allowed under the Health Insurance Portability and Accountability Act (HIPAA) as set forth in our Patient Notice of Privacy Practices which can be found on our website. HIPAA allows us to send written communications to you about treatment, including products and services we offer. However, certain types of communications cannot be sent to you unless you provide written authorization to receive them, namely communications that are sponsored or reimbursed by a third party whose health care products, services or therapies are promoted in the communications sent to patients. You have a choice whether to receive these communications. By completing this registration, you authorize Franklin Wellness to use/disclose your protected health information (PHI) for marketing of health-related products, services or therapies. Franklin Care Store or its business associates may receive financial remuneration in exchange for making the marketing communication from or on behalf of the third party whose product, service or therapy is being described. You acknowledge and understand that this authorization is voluntary. By completing this registration, you acknowledge and understand the following: (1) there is the potential for information used or disclosed pursuant to this authorization to be subject to re-disclosure by the recipient if the recipient is not required by law to protect the privacy of the information; (2) that you may refuse to sign this authorization; however it may prevent Franklin Wellness from completing a task you have requested; (3) that Franklin Care Store will not condition your treatment on whether you provide authorization for the requested use or disclosure if to do so would be prohibited by federal or state law; (4) that you may revoke your authorization in writing to the Privacy Officer of Franklin Care Store at any time, except to the extent that action has been taken in reliance on this statement. By completing this registration, you acknowledge that you have carefully read and understand the above, and do herein expressly and voluntarily authorize the disclosure of your PHI to third parties for the purpose of marketing. A copy of this authorization may be utilized with the same effectiveness as the original. Completion of the signup process acknowledges your acceptance of these terms.
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Franklin IPS LLC. Report Abuse