1. Why do you want to participate in the program? *

2. What do you consider to be your main health problems? *

3. List one or two activities (physical, mental or social) that are important to you, and that your health problem makes difficult or prevents you doing. *

4. What are you hoping to achieve for yourself going through the program? *

5. How would you rate your general well-being during the last week? *

6. How long have you had your main health problems (from above)? *