Survey - Healthy For Good Lifestyle Change | Nomination Form

2018 Southern Maine Heart Walk
Healthy For Good™ Lifestyle Award
Nomination Form

Healthy For Good™ is a revolutionary movement to inspire you to create lasting change in your health and your life, one small step at a time. The approach is simple: Eat smart. Add color. Move more. Be well.

Are you A Healthy For Good™ Hero? The American Heart Association and Anthem BlueCross BlueShield want to recognize individuals who have made or have encouraged someone to make positive changes to improve the quality of their life and health.

Nominations for the Healthy For Good™ Lifestyle Award can be submitted by friends, co-workers or relatives, and individuals can nominate themselves. Winners will be chosen by a volunteer committee.

Click here to print a hard copy of the form. All nominations must be submitted by Tuesday, May 1, 2018.

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Question - Required - Nominee First Name

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Question - Required - Nominee Last Name

Question - Not Required - Company/Work-site (if applicable)

How may we contact the nominee if he or she is selected?

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Question - Required - Nominee's Phone #

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Question - Required - Nominee's Email

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Question - Required - Nominated by

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Question - Required - Phone #

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Question - Required - Email

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Question - Required - Relationship to Nominee

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Question - Required - Please select one:

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Question - Required - Has this person made changes/influenced change in one or more of the following areas?

	EAT SMART. A nutrient dense, well balanced diet (examples include: became educated on healthy eating and cooking, started preparing home cooked meals, plan and prep meals throughout the week to ensure a balanced diet)
	ADD COLOR. Incorporate fruits and vegetables in meals (examples include: shops at local farmer's market, joined a community garden, started their own garden, includes fruit or vegetables in every meal)
	MOVE MORE. Physical Activity (examples include: started an exercise program, started or joined a walking group, joined a gym)
	BE WELL. Includes getting enough sleep, practicing mindfulness, managing stress, keeping mind and body fit, connecting socially, and more (examples include: add balance through meditation, yoga, prioritized self care)

Question - Not Required - Explain what the nominee has done and how they have improved their life of the life of another.

Question - Not Required - Describe the nominee's biggest accomplishment, what you/they are most proud of.

Question - Not Required - What are the nominee's future goals and/or what are they looking forward to?

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Question - Required - If this nominee has maintained a lifestyle change for a year or more, describe how this was accomplished.

Question - Not Required - Additional comments:

(Maximum response 255 chars, approx. 5 rows of text)

2018 Southern Maine Heart Walk
Healthy For Good Lifestyle Change
is locally sponsored by