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  2. 2013
  3. December
  4. H
  5. Healthy Lifestyle
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Exit Survey
 
 
This questionnaire is designed to gain information on the populations view of whether or not they consider themselves to have a healthy lifestyle and whether they want to make a change about it. Please answer the following questions to the best of your ability.
 
 
 
Would you consider yourself to have a healthy lifestyle?
 
Yes
 
No
 
Sometimes
 
 
 
How often do you engage in physical activity?
 
1-2 times a week
 
3 or more times a week
 
Less than once a week
 
 
 
Do you have a gym membership?
 
Yes
 
No
 
 
 
If you answered yes, what gym do you belong to?
   
Why did you choose that gym?
   
 
 
 
If you answered no to having a gym membership what types of physical activity do you engage in?
   
 
 
 
How often do you eat fast food?
 
Once a week
 
3 or more times a week
 
Couple times a month
 
Rarely
 
Never
 
Other
 
 
 
 
Please rank (1-3) the following in order of importance:
Healthy Diet
Being Physically Active
Being Emotionally and Spiritually Happy
 
 
 
How satisfied are you with your lifestyle?
Very Unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied
 
 
 
Do you want you change your lifestyle?
   
If so, how are you going to do this?