Screenshot of Enrollment Questionaire

Lesbian/Bisexual Women's Health Programs Enrollment Form

Welcome to the sign­up page for the San Francisco Bay Area older lesbian/bisexual women's health projects. We are recruiting women for two 
similar free health programs; one from the Lyon Martin Clinic and one from the San Francisco LGBT Center (although we will have group meetings 
in the east bay as well). Complete this form to see if you qualify for the study. 

The two programs are: 
WHAM: Women's Health and Mindfulness is a clinic­based program, led by a professional group facilitator. It includes a visit to the clinic for a 
physical exam and lab tests, including blood draws. The program itself consists of 12 weekly group sessions with support from a dietician and a 
fitness trainer. 

DIFO: Doing It For Ourselves is a community­based program, led by peer facilitators. It includes web or paper and pencil surveys before and after, 
12 weekly group sessions and two hours of individual help from a personal coach. 

Both programs address health, physical activity, nutrition, and stress, all from a lesbian/bisexual woman's perspective. Groups will be forming soon. 

Eligibility

1. Do you identify as a woman? We only care about your identity, not what your physical
body looks like.

j Yes
k
l
m
n
j No
k
l
m
n

2. Do you identify as lesbian, bisexual, queer, two spirit, same gender­loving or a similar
term, and/or consistently have relationships with other women?

j Yes
k
l
m
n
j No
k
l
m
n

3. Are you age 40 or older?

j Yes
k
l
m
n
j No
k
l
m
n

Personal Information

The program was developed for women who at risk for weight­related health problems. These programs focus on a variety of health issues such as 
nutrition, physical activity, and stress. Part of the eligibility criteria is height and weight, although the programs are not focused on weight loss as a 
goal. We acknowledge that asking about weight can be sensitive or offensive to some women, but we are required to collect this information by our 
funder. 

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Lesbian/Bisexual Women's Health Programs Enrollment Form

*4. How tall are you?
j 4 feet 10 inches
k
l
m
n
j 4 feet 11 inches
k
l
m
n
j 5 feet
k
l
m
n

j 5 feet 2 inches
k
l
m
n
j 5 feet 3 inches
k
l
m
n
j 5 feet 4 inches
k
l
m
n
j 5 feet 5 inches
k
l
m
n
j 5 feet 6 inches
k
l
m
n
j 5 feet 7 inches
k
l
m
n
j 5 feet 8 inches
k
l
m
n
j 5 feet 9 inches
k
l
m
n

j 5 feet 10 inches
k
l
m
n
j 5 feet 11 inches
k
l
m
n

j 6 feet 1 inch
k
l
m
n

j 6 feet 2 inches
k
l
m
n
j other
k
l
m
n

j 5 feet 1 inch
k
l
m
n

j 6 feet
k
l
m
n

Other (please specify) 

*5. How much do you weigh?
Commitment

6. Both programs require a lengthy time commitment. Are you willing to commit to
attending the majority of the weekly sessions (12 weeks)? That is, are you pretty sure that
you will not miss more than 4 sessions?

j Yes
k
l
m
n
j No
k
l
m
n

j Maybe
k
l
m
n

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Lesbian/Bisexual Women's Health Programs Enrollment Form
7. Are you willing to complete questionnaires at regular times during the study period?
You will get gift cards for completing surveys.

j Yes
k
l
m
n
j No
k
l
m
n

8. Would you prefer to do questionnaires: (check all that apply)
c online
d
e
f
g

c in person
d
e
f
g
c by mail
d
e
f
g

Contact Information

*9. Someone from the project teams will contact you about your eligibility. Please provide

contact information. What is your name?

*10. What is your email address?

11. What is your phone number?

12. What is your mailing address?

If you qualify for the program, we will be sending you a list of the groups that will be starting up soon, including information about locations, days 
and times. You will be able to choose the group that best suits your needs. 

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