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>Community Health Services>Health Promotion Disease Prevention>Health Promotion Online Registration

Health Promotion Online Registration

Welcome

Health Promotion Online Registration Form

I am interested in the following program: *

Wellness Coaching

Diabetes Prevention Program

Check all that apply: *

Oneida Tribal Member

Other Tribal Affiliation

Oneida Health Center Patient

Oneida Employee (with health insurance)

If you are an Oneida Employee, enter your Employee #

What are you looking to accomplish in the next 3 months? *

Rate the importance for accomplishing your goal above... *

Rate your confidence for accomplishing your goal above... *

Do you have a fitness membership? *

Yes

If you do, where is it?

How many minutes per a week of physical activity do you get?

What might get in the way of accomplishing your goals?

What makes this the right timing for you to join this program?

Do you have any surgeries, vacations, or extended trips that would take you out the program for longer than a week? If so, please give dates.

Have you seen a dietitian or health educator to talk about nutrition and healthy eating?

Yes

Contact Information

First Name *

Last Name Name *

Gender

Male

Female

Birth Date *

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

E-mail

Best time to reach:

Before noon

Between noon and 4pm

After 4pm

Search the Oneida Nation

Health Promotion Disease Prevention Team (L-R) Taylor Jean, Stefanie Reinke, Dawn Krines Glatt, Tahkwatekwa (Tek) Skenandore, Hanna Leisgang, Amanda Riesenberg, Maria Doxtator Alfaro

Phone

(920) 490-3780