The information you provide here will be shared with your Health Stewardship Coach. The goal of this assessment is to help you better understand your own thoughts and motivation and give your coach information that will assist them in supporting you as you work to optimize your personal health.

Name *
I engage (how many) days per week in: AEROBIC EXERCISES - At least 20 minutes of vigorous intensity activity (fitness walking, cycling, jogging, swimming, aerobic dance, active sports) 3 or more days desirable OR at least 30 minutes of moderate intensity activity 5 or more days desirable
I engage (how many) days per week in: STRENGTH EXERCISES - At least 10 minutes of strength-building exercises (such as sit-ups, push-ups, or use strength-training equipment) 2-3 days desirable
I engage (how many) days per week in: FLEXIBILITY or STRETCHING EXERCISES - At least 5 minutes to improve flexibility of your back, neck, shoulders, and legs. 3 days desirable
I previously had the following LIMITATIONS on physical activity, if any, over the last 5 years:
Readiness for Change
My readiness to make changes or improvements in my level of exercise (mark one):
My confidence in my ability to make a positive change regarding my level of exercises is:
My priority for making change in the area of exercise is:
Understanding *
While we never share your information with any 3rd parties, please be advised that the submission and storage of information you provide through this form is not considered secure. Please do not provide any protected health information through this form. If you would prefer to complete a paper version of this form, please contact our office at