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BBM Entrance survey
1.
how many times did you have full sugar fizzy drinks this week?
0
100
Clear
2.
how many times did you have diet fizzy drinks this week to?
0
100
Clear
3.
how many times did you have fruit juice this week?
0
100
Clear
4.
How many times did you eat takeaways or fast foods this week?
Never
1-3 times
4-6 times
7-9 times
10 or more times
5.
How many times did you eat bread/carbs this week?
0
100
Clear
6.
How many times a day do you eat sweets (like chocolates, candy, cookies, etc.)?
0
100
Clear
7.
How many times per week do you exercise or work out?
Every day of the week
Several times per week
Once per week
Less than once per week
I never work out or exercise
8.
In the past 30 days, how many times did you exercise for at least 30 minutes?
Not at all
1 to 4 times
5 to 8 times
9 to 12 times
More than 12 times
9.
About how many cigarettes do you smoke in a typical day?
10.
How many days a week do you drink alcohol?
11.
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
12.
Do you have any injuries that we ought to know about?
Yes
No
13.
If yes, what might that be?
Over the past 2 weeks, how often have you been bothered by any of the following problems?
14.
Having little interest or pleasure in doing things
Not at All
Several Days
More Than Half the Days
Nearly Every Day
15.
Feeling down, depressed, or hopeless
Not at All
Several Days
More Than Half the Days
Nearly Every Day
16.
Having trouble falling or staying asleep, or sleeping too much
Not at All
Several Days
More Than Half the Days
Nearly Every Day
17.
Feeling tired or having little energy
Not at All
Several Days
More Than Half the Days
Nearly Every Day
18.
Having a poor appetite or overeating
Not at All
Several Days
More Than Half the Days
Nearly Every Day
19.
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
20.
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
21.
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
22.
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
23.
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
24.
How did you hear about this position?
Social Media
Word of Mouth
TV
Not until I was contacted and invited to Join
Other (please specify)
25.
On your first day at BBM, did you know anyone else in your group?
No, I didn’t know anyone
Yes, I came with someone I already knew
I know someone who is part of BBM (including following Dave Letele)
Other (please specify)
*
26.
Please leave your name, phone and email address
(Required.)
Name
*
Email Address
Phone Number
*
27.
Client ID
