Lifestyle and Performance Medicine Working Group and Coalition of Interested Intake
This form allows the L&PMWG to discover more information about its members, and will be used to direct interested and experienced individuals toward lines of effort vital to the growth of impactful Lifestyle Medicine activities.
(Current as of 20 July 2021) - Please direct any questions to: LifestylePerformanceMed@gmail.com
Sign in to Google to save your progress. Learn more
Email *
Last Name *
First Name *
Branch of Service *
Work Status *
Grade (Answer only if MIL, i.e. O-5)
Duty Title/Position/Role *
Professional Credentials *
Required
Specialization (if applicable)
.MIL Email Address *
Personal/Secondary Email Address
Preferred Phone (Use: ###-###-####)
Current Permanent Duty Location (i.e. Fort Drum, NY, USA) *
Estimated Date of next Duty or Location Change (i.e. PCS/PCA)
MM
/
DD
/
YYYY
Please explain your interest in Lifestyle & Performance Medicine *
Do you currently serve in any Lifestyle and Performance Medicine Role(s) or Position(s)?
Are you board certified (physician) or professionally certified (allied health care providers) by the American Board of Lifestyle Medicine? (i.e. have you sat for the ABLM exam?)
Clear selection
If you are board certified/professionally certified by  ABLM, what year did you sit for the exam? (i.e. 2018)
Are you certified, or board eligible/certified in other Lifestyle Medicine components? if so, from which organization? (i.e. Board Certified via ACLM, Certified WellCoach, eCornell-T.Collin Campbell-Plant Based Nutrition Certificate)
Please describe your prior efforts in implementing Lifestyle and Performance Medicine -- do you have something you can bring to the working group?
What else would you like the Lifestyle & Performance Medicine Working Group team to know? Do you have any resources, ideas, connections, or recommendations?
Would you like to be connected to other allied health care professionals in your area/at your base who are also interested in Lifestyle & Performance Medicine?
In order to facilitate connection with other health professionals, networking authorization is requested. Do you authorize the following information to be shared from a secure location: Your name, rank, title, credentials, specialty, preferred email, and current location? (Removal can be requested) *
If yes, which email would you prefer shared?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms