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  5. Health Survey
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Questions marked with a * are required Exit Survey
 
Contact Information
First Name : 
Last Name : 
Phone : 
Email Address : 
 
 
 
* How often do you exercise?
 
Daily
 
3 times a week
 
5 times a week
 
almost never
 
 
 
What kind of exercise do you do?
 
 
 
Where do you usually exercise?
 
Gym
 
Home
 
Outdoor
 
Special Facility/ Track
 
Other
 

 
 
 
Do you agree that exercising is important to your health? If disagree you should reconsider that!
 
Strongly Agree
 
Agree
 
Maybe
 
Disagree *you should reconsider that!
 
 
 
How often do you have breakfast?
 
Always
 
Working Days Only
 
Sometimes
 
Never
 
 
 
How often do you eat fast food? "junk food"
 
Daily
 
3 times a week
 
Weekly
 
never
 
 
 
Why do you go to fast food restaurant or eat fast food?
   
 
 
 
Do you think having a healthy breakfast is helpful to your day?
Yes
No
 
 
 
How many meals do you have in a day?
 
One
 
Two
 
Three
 
4 or more