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 *
HEIGHT in inches (without shoes):
WEIGHT in pounds, without shoes, (separated by a forward slash) current/1 year ago/2 years ago/5 years ago/10 years ago:
BMI (calculated by coach):
I have utilized the following weight-management program(s) in the last 10 years (describe):
Ready for Change *
My readiness to make changes or improvements in my weight (mark one):
Confidence *
My confidence in my ability to make a positive change regarding my weight is:
Priority *
My priority for making change in the area of weight (mark one) 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