L.I.F.E! - Membership Starts Here

Primary Member Name (req.)

Primary Email Address (req.)

Address of Household (req.)

Names of Members of Household






 

The information you share is strictly private, protected by HIPPA regulations. It is used for the purpose of showing progress on LIFE membership health initiatives to provide aggregate data as required by our grant funding partners.

 
In general, how would you rate your physical health? (req.)
Please Select:1. Excellent2. Very good3. Good4. Fair5. Poor6. Refused7. Don’t know

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs or carrying groceries? (req.)
Please Select:8. Completely9. Mostly10. Moderately11. A little12. Not at all13. Refused14. Don’t know

In the past 7 days, how would you rate your fatigue on average? (req.)
Please Select:15. None16. Mild17. Moderate18. Severe19. Very severe20. Refused21. Don’t know

Indicate the number of meals you eat away from home during a week: (req.)
Please Select23. Zero24. One to three25. Four to six26. Seven or more

On an average day, how many servings of vegetables and fruits do you eat? (req.)
Please Select27. Zero28. One to three29. Four to six

On an average day, indicate which drink you consume the most? (req.)
Please Select:30. Milk/Dairy Drinks31. Water17. Moderate32. Coffee/Tea33. Soda/Energy Drinks/Fruity or Sports Beverages34 Juices35. Alcohol/Beer/Wine

How many times do you exercise for a minimum of 30 minutes in a week? (req.)
Please Select36. None37. One to three times38. Four or more times39. Everyday

What type of exercise do you participate in most often? (req.)
Please Select40. Walking41. Jogging/Running42. Weight Lifting/Strength Training/Gym Fitness43. Swimming44. Classes ie; yoga, dance, Pilates etc.45. Bicycling

Other forms of exercise?

How many hours during an average night, do you get a good/restful sleep?(req.)
Please Select47. 1-3 hours48. 4-6 hours49. 7-8 hours50. more than 8 hours

 
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