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: