Forest Lane Transformation Challenge, Part III: Recovery Registration and Pre-Assessment Form

The Forest Lane Transformation Challenge is a three-part, movement & nutrition lifestyle program at Forest Lane. We've had people participate in programs in the past and see success, but what happens once that program is over and the new and shiny wears off? By encouraging participants to re-enroll in the subsequent session, this program will build on successes and provide more accountability. This will help participants build and maintain new behaviors so that they become ingrained habits. This is part 3: Recovery.

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
Bi-Weekly group nutrition and movement classes

The program will launch August 5 and will conclude the week of August 26. Classes will be held Monday & Wednesday from 12pm-1pm.

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 7th.

$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 7th.

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* 5. What is your AID/XID?

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* 6. What is your gender?

Male

Female

I prefer not to answer.

Other (please specify)

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* 7. What is your current age?

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* 8. Do you exercise regularly?

Yes

Other (please specify)

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

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

Recovery, Movement & Nutrition

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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* 11. 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 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 regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling).	I regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling). 1- Strongly Disagree	I regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling). 2- Disagree	I regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling). 3- Neither Agree Nor Disagree	I regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling). 4-Agree	I regularly stretch or participate in recovery activities (i.e. yoga, meditation, stretching/foam rolling). 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 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 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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* 12. 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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* 13. 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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* 14. 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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* 15. Please share any additional comments related to the vitality section above.

General Feedback

Forest Lane Transformation Challenge, Part III: Recovery Registration and Pre-Assessment Form

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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. What is your AID/XID?

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* 6. What is your gender?

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* 7. What is your current age?

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* 8. Do you exercise regularly?

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

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

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

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* 13. What best describes you?

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* 14. What best describes you?

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

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* 16. What are you looking forward to in the Forest Lane Transformation Challenge and why?

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* 17. What do you anticipate may challenge you about the the Forest Lane Transformation Challenge, and why?