Rx for Wellness Survey

* Please select your gender.

Male

Female

* Please select your age.

* How would you categorize your tobacco use?

I have never used tobacco

I formerly used tobacco, but have since quit

Occasionally use tobacco products

Regularly use tobacco products

* How many days per week do you continuously exercise for 30 minutes or more?

None

1-2 days per week

3-5 days per week

6-7 days per week

* Do you feel you are getting enough exercise?

Yes

No

Unsure

If you answered "no" to getting enough exercise, what are obstacles you feel prohibit you from getting enough exercise?

I don't have enough time for exercise

Exercising is inconvenient

I'm not interested in exercising

I lack facilities or equipment to use

My health is poor

I am not motivated enough

I feel I do not have proper training

What percentage of the time do you utilize safety belts while in a vehicle?

* How would you describe yourself?

Overweight

Underweight

At desired weight

* How many pounds over or underweight do you feel that you are?

0-5 pounds

6-10 pounds

11-20 pounds

21 pounds or more

Do you eat a well-balanced diet?

Always

Usually

Occasionally

Never