mountsinai

Hello, employees of Mount Sinai Hospital System!

Welcome to the Getting To Know You survey for the Transform program. Please take 5-7 minutes to fill out the items below so we can determine how best to work with you during Transform.

Name *
Name
Phone Number *
Phone Number
Alternate Phone Number
Alternate Phone Number
What is your mailing address? *
What is your mailing address?
From what you know about Transform, which method of communication do you think you will prefer to use with your health coach? You may choose more than one. *
Transform offers weekly check-ins with a professional health coach. What hours are you typically available to talk to your health coach for approximately 15 minutes? You may check more than one time slot. *
Which days of the week would you typically be available to talk to your health coach for approximately 15 minutes? You may check more than one day. *
What is the highest degree or level of education you have completed? *
To what degree are you currently employed?
How would you describe yourself? *
One or more categories may be selected.
Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) *
Have you tried to lose weight before?
You can type things like brisk walking, jogging, swimming, soccer, yoga, hiking, or any other leisure-time physical activity.
In the last 30 days, have you used tobacco?
How would you rate your typical night of sleep? *
In general, how well do you manage your stress? *
How often do you get the social and emotional support you need to help you reach your goals? *
Do you currently follow any special diets that restrict certain foods? *
Approximately how many times are you eating every day? *
Is a large part of your diet influenced by your cultural or ethnic food traditions?
Do you currently practice in any mindful awareness practices, including but not limited to: mindful meditation, deep breathing exercises, yoga, tai chi, or qigong?
If you answered "No" to the above question, have you ever practiced or tried any mindful awareness activities?
Have you participated in a diabetes prevention program in the past? *
In the past 4 weeks (28 days), how often did you do no work at times when you were supposed to be working? *
In the past 4 weeks (28 days), how often did you find yourself not working as carefully as you should? *
In the past 4 weeks (28 days), how often was the quality of your work lower than it should have been? *
In the past 4 weeks (28 days), how often did you not concentrate enough on your work? *
In the past 4 weeks (28 days), how often did health problems limit the kind or amount of work you could do? *
In general, would you say your health is: *
Have you participated in or are you currently participating in other weight loss programs, including Off The Scale or Weight Watchers? *
I acknowledge that I have read the Terms of Service and Privacy Policy and consent to the use of this information by Blue Mesa Health. *