* 1. Sex

* 2. Which category below includes your age?

* 3. In general, how would you rate your overall health?

* 4. Do you currently smoke cigarettes, or not?

* 5. How do you feel about your weight?

* 6. What do you most often do for exercise?

* 7. Would you like Allen to conduct a wellness program?

* 8. If you answered yes to the previous question, in which of the following activites would you consider participating?

* 9. When would you most likely participate? (Please check all that apply.)

* 10. Any additional comments:

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