Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Question Title * 1. First Name OK Question Title * 2. Email OK Question Title * 3. Phone OK Question Title * 4. Occupation Student Student/Athlete Part -Time Worker Hospitality Speciality Skilled Worker Artist/Creative Contracted Worker Medical Field Military Law Enforcement Educator/Coach Manager Executive Entrepreneur Pro Athlete Other (please specify) OK Question Title * 5. Organization (Optional) OK Question Title * 6. Age 12-24 25-32 32-49 50-69 70+ OK Question Title * 7. Which of the following best describes your current relationship status? Married with children Married In a relationship Single N/A OK Question Title * 8. How would you define the state of your health? Not healthy at all Not so healthy Somewhat healthy Very healthy Extremely healthy OK Question Title * 9. How busy are you on an average day? 8+ hours 6-8 hours 4-6 hours 2-4 hours 0-2 hours OK Question Title * 10. Do you feel your day-to-day workload is manageable? All of the time Most of the time Sometimes Hardly ever Never OK Question Title * 11. My job often interferes with my family and social obligations, or personal needs. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK Question Title * 12. What motivates you to address your health? My family Longevity Want to maintain an active lifestyle Want to live pain-free Reduce the risk of disease & illness Boost my confidence & self-esteem Other (please specify) OK Question Title * 13. How would you describe your body type? Muscular Lean Thin Pear Round OK Question Title * 14. Which of the following best describes your athletic background? Played Professionally Competed in college Competed in Highschool Played sports growing up (0-14 years old) No athletic background OK Question Title * 15. How frequently do you workout or participate in recreational activities? Every day A few times a week About once a week A few times a month Once a month OK Question Title * 16. Do you suffer from any medical illness or conditions (How Many) 1-3 4-6 6-9 10+ 0 OK Question Title * 17. Do any diseases or illnesses run throughout your family? Heart disease blood pressure overweight/obesity diabetes cancer none Other (please specify) OK Question Title * 18. Do you currently suffer from any pain or nagging injuries? (How many) 0 1-3 4-6 7-9 10+ OK Question Title * 19. Have you ever had surgery, if so how many? 0 1-3 4-6 7-9 10+ OK Question Title * 20. How regularly do you suffer from shortness of breath? Always Usually Sometimes Rarely Never OK Question Title * 21. Do you stretch daily? Always Usually Sometimes Rarely Never OK Question Title * 22. Estimate how many hours are you active or on your feet per day throughout the workweek? 10+ 7-9 4-6 1-3 less than an hour OK Question Title * 23. Roughly how many hours do you spend seated per day? 10+ 7-9 4-6 1-3 less than an hour OK Question Title * 24. How many cups of water do you drink per day? 0-1 cup 2-4 cups 4-6 cups 7+ OK Question Title * 25. How many meals do you eat per day? 5+ Meal/Snack 3-4 Meal/Snack 1-2 Meal/Snack 0-1 Meal/Snack OK Question Title * 26. How many of your meals are made up of fresh foods 5-6 meals 3-4 meals 2-3 meals 1-2 meals none OK Question Title * 27. Do you drink alcohol? If so, how many days per week? Do not Drink 1-2 2-4 5-7 OK Question Title * 28. Do you smoke? Cigarettes, vaporized smoke pen, marijauna, etc. If so, how many days per week? Do not Smoke 1-2 2-4 5-7 OK Question Title * 29. How many hours do you sleep on average a night? 0-3 hours 4-6 hours 6-8 hours 8+ hours OK Question Title * 30. Rate your quality of sleep on an average night Poor Not so good Sometimes good, sometimes not so good Mostly Great Awesome OK Question Title * 31. Have you ever tracked your sleep? No Yes OK Question Title * 32. Do you go to bed & wake at the same time consistently? Always Usually Sometimes Rarely Never OK Question Title * 33. I feel comfortable in my own skin and will speak what's on my mind when necessary. Always Usually Sometimes Rarely Never OK Question Title * 34. How often are you in a good mood? All the time Most of the time Sometimes Hardly ever Never OK Question Title * 35. Do you get easily annoyed or irritable? All of the time Most of the time Sometimes Hardly ever Never OK Question Title * 36. How often do you feel nervous, anxious, or on edge? All of the time Most of the time Sometimes Hardly ever Never OK Question Title * 37. Do you ever feel so restless that it's hard to sit still? If so, how often? All of the time Most of the time Sometimes Hardly ever Never OK Question Title * 38. My workplace environment is not very pleasant or safe. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree OK DONE
