Haywood 4 Good Screening Survey

All of the information provided through this survey is strictly confidential. The information gathered will not be shared with any outside sources. Your personal information will never be publicly connected to any responses indicated below.

1.Do you agree to the terms outlined in the the provided waiver/agreement?(Required.)

Yes

2.What is your full name?(Required.)

3.Please provide your most used email address. We will NOT bombard your email. It is for your login to Challenge Runner, our platform for Haywood 4 Good.(Required.)

4.How do you identify?

Male

Female

Transgender

I prefer not to answer

5.What is your current age?

7.How much do you currently weigh?

8.If you are currently employed, for whom do you work?
If you are not currently employed, please specify if you are retired, a stay at home parent, unemployed due to COVID-19, or simply unemployed.

9.On average, how often do you participate in cardio activity each week?

150 minutes or more per week (2 hours and 30 minutes a week)

Between 90 minutes and 150 minutes per week

Less than 90 minutes per week

10.On average, how often do you participate in strength training per week?

At least 30 minutes 2 to 3 times per week

Once a week for 30 minutes

I do not participate in weight lifting. Does lifting out of the bed count?

11.On average, how often do you participate in flexibility and balance training per week?

At least 30 minutes 1 to 2 times per week (Yoga)

I occasionally stretch but not for 30 minutes and not every week

I do not stretch. Stretching, what is stretching?

12.On average, how many cups of vegetables do you eat each day?

I regularly eat 2 to 3 cups each day

I eat 1 to 2 cups each day

I rarely eat vegetables. Ew, what are vegetables?

13.On average, how many cups of fruit do you eat each day?

I regularly eat 2 cups each day

I eat 1 cup each day, or two cups occasionally

I don't eat fruit. Ew, what is fruit?

14.On average, how many ounces of lean protein do you eat each day?

I regularly eat 5.5 ounces of lean protein each day (i.e. chicken, fish, tofu, turkey)

I eat 5.5 ounces of protein -- half is lean and half is not

I eat 5.5 ounces of protein but it is rarely lean (i.e., red meat and pork)

15.On average, how many ounces of whole grains do you eat per day?

I eat 6 ounces of whole grains (1 oz = 1 slice of whole grain bread, 1/2 cup cooked brown rice, 1 cup of whole grain cereal)

1 eat 6 ounces of grains -- half are whole and half are not; OR I do not eat grains

I rarely consume grains that are whole (instead, I eat white rice, white bread, sugar cereal)

16.On average, how many cups of vitamin D do you consume each day?

3 cups of dairy (i.e., milk or yogurt) OR 3 cups of non-dairy product (i.e. almond milk, oat milk, or a vitamin D supplement)

I consume less than 3 cups of dairy or alternate dairy product

I do not consume any dairy or alternate dairy product

17.On average, how often do you consume processed sugars?

I consume processed sugar less than 4 times per week (i.e., soda, cake, ice cream, candy); most sugar comes from fruits

I consume processed sugar occasionally but in moderation

I consume processed sugar daily (i.e., soda, sweet tea, candy, etc)

18.On average, how often do you add table salt to your food each day?

I do not add table salt to my food regularly

I add table salt to my food occasionally

I love salt. The more salt the better.

19.On average, how many ounces of water do you drink each day?

I drink half my body weight in ounces of water; OR I drink the "recommended" 8 cups

I occasionally drink half my body weight in ounces of water; OR I occasionally drink 8 cups, but not often

Water? Who needs water?

20.On average, how would you say you handle stress each day?

I am generally happy and optimistic most of the time. I have good coping strategies for stress.

I currently feel somewhat stressed. I could do better with coping with stress.

I feel down and/or stressed more often than not. I cope poorly with stress.

21.On average, how much sleep do you get per night?

I sleep between 7 to 9 hours each night

I sleep between 5 to 7 hours each night

I sleep less than 5 hours each night

22.On average, how often do you use tobacco each day?

I do not use any tobacco products (i.e., cigarettes, vape, e-pen, or chewing tobacco)

I use tobacco occasionally in social settings or during stressful times

I use tobacco daily

I prefer not to answer

23.On average, how often do you consume alcohol?

I consume less than 2 drinks each day

I consume between 2 and 4 drinks each day

I consume more than 4 drinks each day

I prefer not to answer

By submitting the following survey, you understand and agree that you are not guaranteed to be individually rewarded through incentives or prizes while participating in the Haywood 4 Good program.