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* 1. Name

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* 2. Age, Height, Weight

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* 3. Sex

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* 4. Which race/ethnicity best describes you? (Please choose only one.)

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* 5. Would you say that, in general, your health is...

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* 6. In the past 30 days, have you had physical pain or health problems that made it hard for you to do your usual activities such as driving, working around the house, or going to work?

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* 7. How many times do you engage in physical activity or exercise that lasts at least half an hour during a normal week?

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* 8. Please list reasons you may not be exercising (more).

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* 9. Please describe any health or fitness goals you may have. 

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* 10. Would you be interested in additional surveys to help us determine how to run our program to best benefit you?

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