Internal Use Only

2015 Capital Region BetterU Makeover Application

**DEADLINE: FEBRUARY 8, 2015**
Please Return Application To:
Meredith Cohn
American Heart Association
440 New Karner Road, Albany NY 12205
via Fax: 518-869-8180 or Email: Meredith.cohn@heart.org
Questions? Contact: Meredith Cohn via email: meredith.cohn@heart.org or Phone: 518-869-4046

Name:
Address:
City/State:

Zip Code:

E-Mail:

Phone Number:

Date of Birth:

Race (optional):

Please list important aspects of your medical history (i.e. heart disease, high blood pressure, arthritis,
diabetes, etc.)

Yes No Has your doctor ever said that you have a heart condition and that you should only do
physical activity recommended by a doctor?
Yes No Do you feel pain in your chest when you do physical activity?
Yes No In the past month have you had chest pain when you were not doing physical activity?
Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No Do you have bone or joint problems that could be made worse by a change in your physical
activity?
Yes No Do you know any other reason why you should not do physical activity?
If you answered yes to any of the above, would you be willing to get a signed release from your primary
medical provider to participate? Yes No
Would you be willing to get a physical, including biometric screenings prior to participating? Yes No
Brought to you By:

Special thanks to CDPHP for providing health screenings to our participants!

Internal Use Only

2015 Capital Region BetterU Makeover Application

Please indicate what times you are available on each day of the week. Please Note, the American
Heart Association will be committing staff, volunteer and donated resources to this program. This
group typically meets twice a week for educational and/or workout sessions. If you are chosen for
this program, we will work with the times you indicated below. All group sessions are mandatory:
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Will you be able to attend our Go Red for Women Luncheon on May 21st? This will require you to be
available the entire day (8:00 a.m. 3:00 p.m.) and be willing to be a part of the program on that
day. Yes No
Will you be able to attend our kick off on February 17th from 5:30 7:00 p.m.? Yes No
Will you be able to attend an initial health assessment on February 19th to be scheduled between 5:30
and 7:30 p.m.? Yes No
Would you be willing to sign a photo and video release form for interviews, media, and other
promotional purposes? Yes No
Please list any Previous Diet Attempts: ____________________________________________________
____________________________________________________________________________________
Please indicate your Current and Past Activities
Weight Training Cardio Training Yoga Pilates Dance Other (What?)______________
Active hobbies or sports: ___________________________How often:___________________________
Do you belong to a gym? Yes No If Yes, which one?_____________________________________
Please rate your readiness to change from 1-5 (1no interest in making major lifestyle changes, 5
very ready to make the changes necessary to prevent or treat heart disease): __________________
Will you be able to participate for the entire 12 weeks? Yes No
Would you be able to attend value-added wellness sessions (grocery store tours, cooking demos, etc.)?
Yes No
Brought to you By:

Special thanks to CDPHP for providing health screenings to our participants!

Internal Use Only

2015 Capital Region BetterU Makeover Application

Tell us about your Job/School/Activities:___________________________________________________

____________________________________________________________________________________
What is your stress level: High Medium Low
Do you smoke cigarettes? Yes No If yes, are you looking to quit? Yes No
Tell us about your goals! What 3 things will you accomplish if chosen as a participant in the BetterU
Makeover Challenge? (Please be as specific as possible,)
1) _________________________________________________________________________________
_________________________________________________________________

_________________

2) _________________________________________________________________________________
___________________________________________________________________

______________

3) _________________________________________________________________________________
______________________________________________________________________

____________

In 100 words or less, please let us know why you want to participate in the 2015 BetterU Makeover
Program and why you should be chosen (use additional space if needed):

Brought to you By:

Special thanks to CDPHP for providing health screenings to our participants!