Sherman Lake YMCA Health Seeker - Kids Survey
RequiredRequired Question(s)

Borgess Pro-Med Pediatrics, the Sherman Lake YMCA and United Health Care are collaborating to promote healthy lifestyles in children.   Any program developed would be supervised by a Pediatric Physician, a Certified Nutritionist and Child Physiologist.   Sherman Lake YMCA would provide an experienced counselor to facilitate activities and provide information for families at their site in Augusta, Michigan.  Currently, we are focusing on children that have been diagnosed as being clinically above height/weight norms.

In order to provide the program that works with your family, we are collecting information regarding timing, interest and finanical assistance needs.  All information will be kept confidential and data will be used on an individual basis only at your request by completing the family information portion of this survey.

Your family has been referred by your physician, school counselor or nurse.  Thank you for taking your time to complete this survey.
 
Required 1.

Who referred you to this program?
Family doctor or pediatrician
Referral from friend, family or acquaintance
School Counselor, PE instructor, nurse or teacher
Sherman Lake YMCA
Other
  • Comment:

  • 500 characters left.
Required 2.

What day of the week works best with your family's schedule?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Required 3.


Would your family be able to commit to a multi-week program?  Which of the following would be the most advantageous for your family?
4 weeks
8 weeks
12 weeks
Drop-in
Other
  • Comment:

  • 500 characters left.
Required 4.

What time frame works best with your daily schedule?
9:00am to 11:00am
11:00am to 1:00pm
1:00pm - 3:00pm
3:00pm - 5:00pm
5:00pm - 7:00pm
Other  
  • Comment:

  • 500 characters left.
Required 5.

Do you have a child with a Body Mass Index (BMI) of any listed below?    CDC Site for Calculation :  http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
Over 75%
Over 85%
Over 95%
Not sure
No
  • Comment:

  • 500 characters left.
6.

Does your child need any special assistance at school?
Dietary Needs
Educational
Social
Physical
Prefer not to answer
Other  
  • Comment:

  • 500 characters left.
Required 7.

Is your child covered by medical insurance currently?
YES
NO
Required 8.

Would a fee based program be a finanical burden on your family at this time?
Yes, we may need some finanical support.
No, not if priced reasonably
  • Comment:

  • 500 characters left.
Required 9.

What type of programs might best fit your child's interest?
 Least Likely Likely Most Likely   
Weekly group focused on age appropriate activities through the year   
Drop in programs for all ages with varied activities   
Structure on-focus physical activity   
Structured lifetime activity based on healthy choices   
Suggestions   
  • Comment:

  • 500 characters left.
Required 10.

What age range best describes the child that has weight concerns?
0-3 years
4-6 years
7-9 years
10-12 years
12-14 years
14-16 years
17 & 18 years
11.

If you are interested in more information about our programs, please complete the family data fields below:

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code: