Name
Email
How would you rate your overall health when compared to your peers
Much better than my peers
A little better than my peers
About the same as my peers
A little worse than my peers
Much worse than my peers
How would you rate your physical activity?
Much more active than my peers
A little more active than my peers
About the same as my peers
A little less active than my peers
Much less active than my peers
How would you rate your dietary habits?
Much better than my peers
A little better than my peers
About the same as my peers
A little worse than my peers
Much worse than my peers
How often do you think about your physical health?
Almost never
Occasionally
Somewhat often
Very Often
Daily
In the last 6 months have you had any concern for your weight?
Significant concern
Moderate Concern
Mild Concern
No Concern at all
Which of the following diets/methods are you familiar with (Select all that apply)
Weight-Watchers
South Beach/Low Carb
Ketogenic
Carnivore
Vegan
Vegetarian
Intermittent Fasting
Which of the following diets (if any) have you tried? Select all that apply
Weight-Watchers
South Beach
Ketogenic
Carnivore
Vegan
Vegetarian
Intermittent Fasting
Which of the following exercise methods have you participated in within the last 6 months (select all that apply)
Weightlifting (general)
“Cardio” (Running,Walking,Cycling,Rowing,etc.)
Swimming or “Aquatic Exercises”
HIIT (High Intensity Interval Training)
Crossfit or Olympic Lifting
Powerlifting
Yoga
Martial Arts
Traditional Sports
Other
Overall, how satisfied are you with the trajectory of your health over the last year?
Extremely satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Extremely Dissatisfied
How would you rate you ability to engage in/ enjoy your favorite recreational activities?
Full participation/ zero restriction
Minimal Restriction
Moderate Restriction
Minimal Participation/Heavy Restriction
Unable to participate
How optimistic are you that your health will improve over the next 6 months?
Very optimistic
Somewhat optimistic
Neutral
Not at all optimistic
Which of the following present an obstacle to increasing the quality of your health? (Select all that apply)
Knowledge
Injury
Medical Condition
Schedule
Travel
Peer Pressure
Expectations of others
Holiday Season
Not Identifiable but “Feeling Stuck”
Are you interested in receiving educational materials, resources or coaching to improve your current health and level of fitness? (At no cost to you)
Yes
No
Depends
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