BBM Exit survey Question Title * 1. What did you enjoy about the FTC program Question Title * 2. Did you lose any weight? Yes No Question Title * 3. If yes, how many kg Question Title * 4. Did you use any of the printouts or resources that were provided during the nutrition sessions? Yes No Question Title * 5. If so, which ones? Question Title * 6. Did you do any of the workouts and exercises from home in your own time? Yes No Question Title * 7. If so, which ones? Question Title * 8. Did you miss any classes? If so why Question Title * 9. On a rating scale of 1 to 5 - Did the From the Couch Program meet your expectations for improving your health? 1 - Definitely not 2 - Not quite 3 - Some 4 - Yes mostly 5 - Definitely Yes Improved Health Improved Health 1 - Definitely not Improved Health 2 - Not quite Improved Health 3 - Some Improved Health 4 - Yes mostly Improved Health 5 - Definitely Yes Question Title * 10. Please finish this sentence: Now that I've completed the 12 week FTC program, I plan to Question Title * 11. How many times did you have Fizzy drinks this week? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 12. How many times did you eat take aways at fast food restaurants this week? Never 1-3 times 4-6 times 7-9 times 10 or more times Question Title * 13. How many times did you eat bread/carbs this week? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 14. How many times a day do you eat sweets (like chocolates, candy, cookies, etc.)? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 15. How many BBM exercise sessions have you attended in total? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 16. How many BBM nutrition session have you attended? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 17. About how many cigarettes do you smoke in a typical day? Question Title * 18. How many days a week do you drink alcohol? Question Title * 19. When you drink alcohol, how many drinks do you usually have? (1 drink=1 can of beer or a small glass of wine)? 0 1-4 5-8 9-12 13-16 More than 16 Question Title * 20. Did you ever feel like you were in pain because of any exercises you did - was the gain worth the pain? Yes No Over the past 2 weeks, how often have you been bothered by any of the following problems? Question Title * 21. Having little interest or pleasure in doing things Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 22. Feeling down, depressed, or hopeless Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 23. Having trouble falling or staying asleep, or sleeping too much Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 24. Feeling tired or having little energy Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 25. Having a poor appetite or overeating Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 26. Feeling bad about yourself — or that you are a failure or have let yourself or your family down Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 27. Having trouble concentrating on things, such as reading the newspaper or watching television Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 28. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 29. Having thoughts that you would be better off dead or of hurting yourself in some way Not at All Several Days More Than Half the Days Nearly Every Day Question Title * 30. How difficult have any of these problems above made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Question Title * 31. Would you be interested in participating in future research, following up on your health? Yes No Question Title * 32. Please leave your name/email if you'd like for us to contact you (optional) Name Email Address Phone Number Question Title * 33. Mindbody ID# Question Title * 34. What is your Date of Birth? DOB Date Done
