SWAP IT TO DROP IT! Community Health Challenge Fall 2012 - Pre-program SurveySWAP IT TO DROP IT! Community Health Challenge Fall 2012

1. First Name:

First Name:

2. Middle Initial:

Middle Initial:

3. Last name:

Last name:

4. Please provide your contact information (Providing an email is optional, but it is necessary if you want to receive weekly email messages):

Please provide your contact information (Providing an email is optional, but it is necessary if you want to receive weekly email messages): Address:
Address 2 (optional):
City/Town:
State:
ZIP:
Email Address:
Phone Number:

Providing the information below will help us evaluate this program by helping us understand who participates, what changes participants make during the program, and how we can improve future community programs.

5. Age:

Age:

6. Gender:

Gender: Female

Male

Choose not to answer

7. Weight:

Weight:

8. Height:

Height: Feet
Inches

9. Do you currently smoke?

Do you currently smoke? Yes

No, I quit

No, I never smoked

Don’t know/choose not to answer

SWAP IT TO DROP IT! Community Health Challenge Fall 2012 - Pre-program Survey

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