Forest Lane Live Better Program Registration and Pre-Assessment Form

The Forest Lane Live Better program is a 12-week program at (South Campus) Forest Lane that involves the four pillar approach to a healthy lifestyle: mindset, nutrition, movement, and recovery. The Forest Lane Live Better program is a group lifestyle program targeted towards individuals looking to make health improvements.

The program includes:

Starter kit (Texins water bottle and journal)
Individual pre and post assessments (quality of life assessment, nutrition and health assessment, functional movement screen, body composition, and weight)
(3) One-on-one sessions with a Registered Dietitian and Health Fitness Specialist
Finisher t-shirt
Weekly group nutrition, mindset/recovery, walking, and movement classes

Assessments will take place the week of August 21st with the program launching the week of August 28th and concluding the week of November 13th.

Cost: $50 for Texins members and $140 for non-members

The goal of this survey is to gauge where you stand in areas relating to aspects of wellness. By assessing your current habits that contribute to your daily performance and future success, you will receive feedback and support to put simple actions in place for yourself.

This survey will take you 10 minutes to complete.

Basic Information

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. Program Cost: $50 (Texins Members) and $140 (Non-Texins Members). Please select your payment option.

$50 Texins Member, Payroll deduction (TI employees only). By selecting this option you are authorizing Texins to proceed with the $50 payroll deduction charge.

$50 Texins Member, Credit Card. Please provide credit card payment at the front desk at Texins Fitness Center by August 21st.

$140 Non-Texins Member, Payroll deduction (TI employees only).By selecting this option you are authorizing Texins to proceed with the $140 payroll deduction charge.

$140 Non-Texins Member, Credit Card. Please provide credit card payment at the front desk at Texins Fitness Center by August 21st.

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* 5. Please, list what days and times you would be interested in attending group classes:

	Monday	Tuesday	Wednesday	Thursday
7 AM - 7:30 AM	7 AM - 7:30 AM Monday	7 AM - 7:30 AM Tuesday	7 AM - 7:30 AM Wednesday	7 AM - 7:30 AM Thursday
7:30 AM- 8 AM	7:30 AM- 8 AM Monday	7:30 AM- 8 AM Tuesday	7:30 AM- 8 AM Wednesday	7:30 AM- 8 AM Thursday
8 AM - 8:30 AM	8 AM - 8:30 AM Monday	8 AM - 8:30 AM Tuesday	8 AM - 8:30 AM Wednesday	8 AM - 8:30 AM Thursday
11 AM - 11:30 AM	11 AM - 11:30 AM Monday	11 AM - 11:30 AM Tuesday	11 AM - 11:30 AM Wednesday	11 AM - 11:30 AM Thursday
11:30 AM - 12 PM	11:30 AM - 12 PM Monday	11:30 AM - 12 PM Tuesday	11:30 AM - 12 PM Wednesday	11:30 AM - 12 PM Thursday
12 PM- 12:30 PM	12 PM- 12:30 PM Monday	12 PM- 12:30 PM Tuesday	12 PM- 12:30 PM Wednesday	12 PM- 12:30 PM Thursday
4 PM - 4: 30 AM	4 PM - 4: 30 AM Monday	4 PM - 4: 30 AM Tuesday	4 PM - 4: 30 AM Wednesday	4 PM - 4: 30 AM Thursday
4:30 AM - 5 PM	4:30 AM - 5 PM Monday	4:30 AM - 5 PM Tuesday	4:30 AM - 5 PM Wednesday	4:30 AM - 5 PM Thursday

Other (please specify)

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* 6. Assessments will take place at the beginning and end of the program. Assessments will be a one-on-one session with the Registered Dietitian and Health Fitness Specialist. It will take 1 hour to complete the assessment. Please indicate what days/times work best for you during these two weeks:

	Monday	Tuesday	Wednesday	Thursday	Friday
8 AM - 9 AM	8 AM - 9 AM Monday	8 AM - 9 AM Tuesday	8 AM - 9 AM Wednesday	8 AM - 9 AM Thursday	8 AM - 9 AM Friday
9 AM -10 AM	9 AM -10 AM Monday	9 AM -10 AM Tuesday	9 AM -10 AM Wednesday	9 AM -10 AM Thursday	9 AM -10 AM Friday
10 AM - 11 AM	10 AM - 11 AM Monday	10 AM - 11 AM Tuesday	10 AM - 11 AM Wednesday	10 AM - 11 AM Thursday	10 AM - 11 AM Friday
11 AM - 12 PM	11 AM - 12 PM Monday	11 AM - 12 PM Tuesday	11 AM - 12 PM Wednesday	11 AM - 12 PM Thursday	11 AM - 12 PM Friday
2 PM - 3 PM	2 PM - 3 PM Monday	2 PM - 3 PM Tuesday	2 PM - 3 PM Wednesday	2 PM - 3 PM Thursday	2 PM - 3 PM Friday
3 PM - 4 PM	3 PM - 4 PM Monday	3 PM - 4 PM Tuesday	3 PM - 4 PM Wednesday	3 PM - 4 PM Thursday	3 PM - 4 PM Friday

Other (please specify)

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* 7. Are you a TI employee?

Yes

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* 8. If you are a TI employee please list your AID/XID. If not, put N/A.

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* 9. What is your gender?

Male

Female

I prefer not to answer.

Other (please specify)

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* 10. What is your current age?

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* 11. Do you exercise regularly?

Yes

Other (please specify)

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* 12. Please specify what type(s) of exercise you currently engage in.

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* 13. How much time do you typically exercise weekly, in minutes?

Personal Vitality

This section will ask questions about your current habits and rituals.

There are no right or wrong answers. Simply select the response that best represents you or that represents you most of the time.

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* 14. Please indicate how much you agree or disagree with each statement below. On a scale of 1-5 (1 being low and 5 being high), please rate the following:

	1- Strongly Disagree	2- Disagree	3- Neither Agree Nor Disagree	4-Agree	5-Strongly Agree
I usually wake up feeling refreshed.	I usually wake up feeling refreshed. 1- Strongly Disagree	I usually wake up feeling refreshed. 2- Disagree	I usually wake up feeling refreshed. 3- Neither Agree Nor Disagree	I usually wake up feeling refreshed. 4-Agree	I usually wake up feeling refreshed. 5-Strongly Agree
I generally feel that my body is strong, balanced, and functional enough to do the things I want to do.	I generally feel that my body is strong, balanced, and functional enough to do the things I want to do. 1- Strongly Disagree	I generally feel that my body is strong, balanced, and functional enough to do the things I want to do. 2- Disagree	I generally feel that my body is strong, balanced, and functional enough to do the things I want to do. 3- Neither Agree Nor Disagree	I generally feel that my body is strong, balanced, and functional enough to do the things I want to do. 4-Agree	I generally feel that my body is strong, balanced, and functional enough to do the things I want to do. 5-Strongly Agree
I typically monitor my hydration and have water available throughout the day.	I typically monitor my hydration and have water available throughout the day. 1- Strongly Disagree	I typically monitor my hydration and have water available throughout the day. 2- Disagree	I typically monitor my hydration and have water available throughout the day. 3- Neither Agree Nor Disagree	I typically monitor my hydration and have water available throughout the day. 4-Agree	I typically monitor my hydration and have water available throughout the day. 5-Strongly Agree
I regularly eat a variety of fruits and vegetables.	I regularly eat a variety of fruits and vegetables. 1- Strongly Disagree	I regularly eat a variety of fruits and vegetables. 2- Disagree	I regularly eat a variety of fruits and vegetables. 3- Neither Agree Nor Disagree	I regularly eat a variety of fruits and vegetables. 4-Agree	I regularly eat a variety of fruits and vegetables. 5-Strongly Agree
I take regular breaks throughout the day to recharge.	I take regular breaks throughout the day to recharge. 1- Strongly Disagree	I take regular breaks throughout the day to recharge. 2- Disagree	I take regular breaks throughout the day to recharge. 3- Neither Agree Nor Disagree	I take regular breaks throughout the day to recharge. 4-Agree	I take regular breaks throughout the day to recharge. 5-Strongly Agree
I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains.	I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains. 1- Strongly Disagree	I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains. 2- Disagree	I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains. 3- Neither Agree Nor Disagree	I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains. 4-Agree	I frequently prepare myself mentally and physically before meetings to keep them from becoming energy drains. 5-Strongly Agree
I usually reframe my negative thoughts into more positive ones.	I usually reframe my negative thoughts into more positive ones. 1- Strongly Disagree	I usually reframe my negative thoughts into more positive ones. 2- Disagree	I usually reframe my negative thoughts into more positive ones. 3- Neither Agree Nor Disagree	I usually reframe my negative thoughts into more positive ones. 4-Agree	I usually reframe my negative thoughts into more positive ones. 5-Strongly Agree
I regularly take time to reflect on things I did well in various situations.	I regularly take time to reflect on things I did well in various situations. 1- Strongly Disagree	I regularly take time to reflect on things I did well in various situations. 2- Disagree	I regularly take time to reflect on things I did well in various situations. 3- Neither Agree Nor Disagree	I regularly take time to reflect on things I did well in various situations. 4-Agree	I regularly take time to reflect on things I did well in various situations. 5-Strongly Agree
I usually don't have a problem falling asleep when I go to bed.	I usually don't have a problem falling asleep when I go to bed. 1- Strongly Disagree	I usually don't have a problem falling asleep when I go to bed. 2- Disagree	I usually don't have a problem falling asleep when I go to bed. 3- Neither Agree Nor Disagree	I usually don't have a problem falling asleep when I go to bed. 4-Agree	I usually don't have a problem falling asleep when I go to bed. 5-Strongly Agree
I typically don't have pain when doing things throughout the day.	I typically don't have pain when doing things throughout the day. 1- Strongly Disagree	I typically don't have pain when doing things throughout the day. 2- Disagree	I typically don't have pain when doing things throughout the day. 3- Neither Agree Nor Disagree	I typically don't have pain when doing things throughout the day. 4-Agree	I typically don't have pain when doing things throughout the day. 5-Strongly Agree
I understand what personal values are important to me as an individual.	I understand what personal values are important to me as an individual. 1- Strongly Disagree	I understand what personal values are important to me as an individual. 2- Disagree	I understand what personal values are important to me as an individual. 3- Neither Agree Nor Disagree	I understand what personal values are important to me as an individual. 4-Agree	I understand what personal values are important to me as an individual. 5-Strongly Agree
I frequently incorporate my values into the actions I take.	I frequently incorporate my values into the actions I take. 1- Strongly Disagree	I frequently incorporate my values into the actions I take. 2- Disagree	I frequently incorporate my values into the actions I take. 3- Neither Agree Nor Disagree	I frequently incorporate my values into the actions I take. 4-Agree	I frequently incorporate my values into the actions I take. 5-Strongly Agree
I can usually avoid feeling tired throughout the day.	I can usually avoid feeling tired throughout the day. 1- Strongly Disagree	I can usually avoid feeling tired throughout the day. 2- Disagree	I can usually avoid feeling tired throughout the day. 3- Neither Agree Nor Disagree	I can usually avoid feeling tired throughout the day. 4-Agree	I can usually avoid feeling tired throughout the day. 5-Strongly Agree
I typically have the energy to do the things I want to do when I get home from work.	I typically have the energy to do the things I want to do when I get home from work. 1- Strongly Disagree	I typically have the energy to do the things I want to do when I get home from work. 2- Disagree	I typically have the energy to do the things I want to do when I get home from work. 3- Neither Agree Nor Disagree	I typically have the energy to do the things I want to do when I get home from work. 4-Agree	I typically have the energy to do the things I want to do when I get home from work. 5-Strongly Agree
I feel like I am more resistant to common illnesses than the average person.	I feel like I am more resistant to common illnesses than the average person. 1- Strongly Disagree	I feel like I am more resistant to common illnesses than the average person. 2- Disagree	I feel like I am more resistant to common illnesses than the average person. 3- Neither Agree Nor Disagree	I feel like I am more resistant to common illnesses than the average person. 4-Agree	I feel like I am more resistant to common illnesses than the average person. 5-Strongly Agree
I usually wake up looking forward to my day.	I usually wake up looking forward to my day. 1- Strongly Disagree	I usually wake up looking forward to my day. 2- Disagree	I usually wake up looking forward to my day. 3- Neither Agree Nor Disagree	I usually wake up looking forward to my day. 4-Agree	I usually wake up looking forward to my day. 5-Strongly Agree

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* 15. On a scale of 1-5 (1 being low and 5 being high), please rate the following.

	1	2	3	4	5
How would you rate your energy to mentally get through your day?	How would you rate your energy to mentally get through your day? 1	How would you rate your energy to mentally get through your day? 2	How would you rate your energy to mentally get through your day? 3	How would you rate your energy to mentally get through your day? 4	How would you rate your energy to mentally get through your day? 5
How would you rate your energy to physically get through your day?	How would you rate your energy to physically get through your day? 1	How would you rate your energy to physically get through your day? 2	How would you rate your energy to physically get through your day? 3	How would you rate your energy to physically get through your day? 4	How would you rate your energy to physically get through your day? 5

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* 16. What best describes you?

I am not currently thinking of changing my nutrition.

I am thinking about making changes to my nutrition.

I am taking some action around nutrition.

I have already made some changes to my nutrition, and I am continuing to work on changing more.

I have made changes to my nutrition and have been doing them consistently for the past 6 months.

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* 17. What best describes you?

I am not currently thinking of changing my exercise habits.

I am thinking about making changes.

I am taking some action around my exercise habits.

I have already made some changes to my exercise habits and am continuing to work on changing more.

I have made changes to my exercise habits and have been doing them consistently for the past 6 months.

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* 18. Please share any additional comments related to the vitality section above.

General Feedback

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. Program Cost: $50 (Texins Members) and $140 (Non-Texins Members). Please select your payment option.

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* 5. Please, list what days and times you would be interested in attending group classes:

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* 6. Assessments will take place at the beginning and end of the program. Assessments will be a one-on-one session with the Registered Dietitian and Health Fitness Specialist. It will take 1 hour to complete the assessment. Please indicate what days/times work best for you during these two weeks:

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* 7. Are you a TI employee?

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* 8. If you are a TI employee please list your AID/XID. If not, put N/A.

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* 9. What is your gender?

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* 10. What is your current age?

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* 11. Do you exercise regularly?

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* 12. Please specify what type(s) of exercise you currently engage in.

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* 13. How much time do you typically exercise weekly, in minutes?

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* 14. Please indicate how much you agree or disagree with each statement below. On a scale of 1-5 (1 being low and 5 being high), please rate the following:

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* 15. On a scale of 1-5 (1 being low and 5 being high), please rate the following.

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* 16. What best describes you?

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* 17. What best describes you?

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* 18. Please share any additional comments related to the vitality section above.

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* 19. What are you looking forward to in the Forest Lane Live Better program and why?

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* 20. What do you anticipate may challenge you about the the Forest Lane Live Better program, and why?