Survey

Name *

First Name

Last Name

Phone

(###)

###

####

Survey *

I care about about my health

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I go out of my way to to make healthy lifestyle choices

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am happy with the amount of physical activity I do

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have lots of energy throughout the day

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I get 7-8 hours of sleep per night

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am happy with the way that I look and feel

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I want to improve my health and fitness

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree