LiveWell.org - Disclaimer

Become a LiveWell Member

LiveWell is a FREE program available to all Mesa County adults. LiveWell encourages and rewards you for making the choice to live a healthier lifestyle. By registering you will receive resources and be eligible for great prizes!

Congratulations on making the choice to LiveWell!

First Name:
Last Name:
Street Address:
City:
Zip Code:
Phone Number:
Would you like to be sent the LiveWell Monthly Newsletter via e-mail?	Yes No
Would you like to be sent LiveWell updates via e-mail?	Yes No
E-mail:
Preferred Shirt Size
1. Please type your healthcare provider's name
1A. Can we give your healthcare provider information about your participation in the program?	Yes No
2. If you were referred to LiveWell by your healthcare provider, please print the referral number (bottom right hand corner of referral note): #
3. Are you a VA patient in Grand Junction, CO?	Yes No
4. How would you rate overall health right now?
5. Check any items that apply to you. (These questions will assess your risk for developing diabetes) 5A. I have/had a sister or brother with diabetes.	Yes No
5B. I have/had a parent with diabetes.	Yes No
5C. I am under 65 years of age and I get little or no exercise.	Yes No
5D. I am a woman who has had a baby weighing more than nine pounds at birth.	Yes No
6. Check YES for any of the following health problems you have been told by your doctor or nurse that you have or may be at risk for. 6A. Been told you have/ are at risk for: Arthritis?	Yes No
6B. Been told you have/ are at risk for: Asthma?	Yes No
6C. Been told you have/ are at risk for: Heart disease of any kind?	Yes No
6D. Been told you have/ are at risk for: High blood pressure?	Yes No
6E. Been told you have/ are at risk for: High cholesterol?	Yes No
6F. Been told you have/ are at risk for: Type I Diabetes?	Yes No
6G. Been told you have/ are at risk for: Type II Diabetes?	Yes No
6H. Been told you have/ are at risk for: Overweight/Obesity?	Yes No
6I. Been told you have/ are at risk for: Kidney disease?	Yes No
6J. Been told you have/ are at risk for: Other?	Yes No
7. Suppose you were going to exercise continuously on an indoor track for 1 mile. Which exercise pace is just right for you (not too easy and not too hard)?
8. Choose the description that best describes your level of physical activity over the past 6 months
9. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)
10. On an average day, how many hours do you watch TV?
11. On average, how many servings of fruits and vegetables do you eat each day? A serving size is the size of a fist (in general).
12. Which of the following best describes your behavior toward tobacco?
13. Which of the following best describes your race/ethnicity?
14. What is your date of birth? (month/day/year)
15. What is your gender?	Male Female
16. What is your height?	Feet Inches
17. What is your weight (pounds)?
18. Where do you work? (Do not abbreviate)
19. Including yourself, how many people live in your home?	Adult Children
20. Do you agree to the terms and conditions found here?	Yes No
21. Please type in your full name for your digital signature:

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