Koops Survey

1. How would you rate your overall health?

How would you rate your overall health? Excellent

Good

Average

Poor

2. How would you rate your current dietary habits?

How would you rate your current dietary habits? Excellent

Good

Average

Poor

3. How many days per week do you get 30 minutes (or more) of exercise?

How many days per week do you get 30 minutes (or more) of exercise? 0-2

3-5

6 or more

4. If you answered 0-2 days per week above, what is the main reason you do not get more exercise per week?

If you answered 0-2 days per week above, what is the main reason you do not get more exercise per week? Don’t have time

Unable to exercise due to health condition/injury

Not interested in exercise

Get enough physical activity through my job

Other

Other (please specify)

5. Which of Priority Health’s five “Health By Choice” biometric requirements do you have trouble meeting? (Mark all that apply)

Which of Priority Health’s five “Health By Choice” biometric requirements do you have trouble meeting? (Mark all that apply) Non-tobacco user

Body mass index

Cholesterol

Blood pressure

Blood sugar

I do not have trouble meeting the “Health By Choice” requirements

6. Which of the following wellness topics are you interested in learning more about?

Which of the following wellness topics are you interested in learning more about? Nutrition/healthy eating Weight management/metabolism Avoiding and taking care of sports injuries Cholesterol reduction	Blood pressure reduction Reducing diabetes risk Stress reduction Men’s health issues	Women’s health issues Other
Other (please specify)

7. Would your spouse be interested in wellness opportunities offered through Koops?

Would your spouse be interested in wellness opportunities offered through Koops? Yes

8. Which of the following wellness program activities would you participate in at Koops?

Which of the following wellness program activities would you participate in at Koops? Fitness facility (Holland Aquatic Center) incentive

Health Assessments (Blood pressure, weight)

Monthly Exercise Tracking incentive

Wellness Classes

Koops 3-a-thons & other activities

None of the above

9. If you do not participate in the wellness program, why not?

If you do not participate in the wellness program, why not? Don’t really care.

Topics are not interesting/relevant to me.

Don’t have time.

Incentives to participate are not worth it.