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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. At what email address would you like to be contacted?

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* 4. Enter your birthdate: 

Date

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* 5. What is your gender?

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* 6. What is your height? (inches)

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* 7. What is your current weight (pounds)?

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* 8. Are you currently in pain?

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* 10. If you have pain, have you seen a physician for this pain?

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* 11. If you have seen a physician, have you been released to return to full activity?

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* 12. In the past year, have you had an injury/surgery that caused you to miss 1 or more exercise sessions or your work?

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* 13. If you have EVER had a previous injury/surgery, rate your function (how back to "normal" do you feel?) on the scale 0% (No Function) to 100% (No Limitations/Normal)

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 14. Do you exercise at least 2 days a week for 20 minutes each?

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* 15. In general, would you say your health is:

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* 16. Which of the following best describes your activity level outside of work?

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* 17. How many days per week do you participate in your activity?

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* 18. How many minutes would it take you to run/walk one mile?

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* 19. Do you have a goal to increase your activity level?

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* 20. Do you feel tense?

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* 21. Do you feel a cold sensation in your hands or feet?

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* 22. Do you notice yourself yawning?

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* 23. Do you notice breathing through your mouth at night?

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* 24. Do your currently smoke regularly?

T