Project Life-Change Survey

1. What is your age?
18-24
25-40
41-60
Over 60
2. Are you male or female?
Male
Female

3. Are you a:
College Student
Faculty Member
Staff Member
Community Member
4. What is your race? Please choose one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Other
5. What is your approximate average household income?
$0-$24,999
$25,000-$49,999
$50,000-$99,999
$100,000-above

6. What is the highest level of school you have completed or the highest degree you have
received?
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree/Professional
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Part B


7. Are you exercising more than 30 minutes per day on a regular basis?
Yes
No
Sometimes

8. What type of exercise are you engaging in on a regular basis? (Check all that apply)
I am not exercising currently
Walking
Jogging
Swimming
Cycling
Exercise Class
Yoga
Aerobics
Weight Lifting
Athletic Activities
Other (please specify)
9. If you are exercising, where are you doing this activity?
My home
YMCA
Fitness Center
Local School
Other (please specify)
10. What types of activities would you participate in if they were available in this area? (Check
all that apply)
Classes
Individual Workouts
Walking
Cycling
Swimming
Aerobics
Yoga
Kettlebell
Circuit Training
Free Weight Training
Exercise Bands
Sport Specific such as volleyball, basketball, etc.
Other (please specify)
11. How many times per week do you eat fast food that is not on the healthy menu?
I do not eat fast food
Once a week
Twice a week
Three times a week
Four times or more per week

12. What type of food do you order from fast food restaurants? (Check all that apply)
I do not eat fast food
Hamburgers
Chicken
Salads
French Fries
Pizza
Desserts
Tacos
Breakfast Biscuits
Other (please specify)



Part C


13. If you wanted to lose weight, how much weight would you like to lose?
I am not interested in losing weight
5-10 Pounds
11-20 Pounds
21-40 Pounds
41 or More Pounds

14. Why do you want to lose weight?
To look better
To feel better
To decrease risk of diseases like diabetes
My family wants me to
To increase my level of activity
Other (please specify)

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15. In your opinion, would you say you are a healthy person?
Not Healthy
Somewhat Healthy
Healthy
Very Healthy
16. What is the biggest obstacle you face when trying to make healthier choices such as eating
healthy food and exercising regularly?

Never Sometimes Always
a. Lack of Time
*What is the biggest
obstacle you face when
trying to make healthier
choices such as eating
healthy food and
exercising regularly? a.
Lack of Time Never
a. Lack of Time
Sometimes
a. Lack of Time
Always
b. Lack of
Motivation
b. Lack of
Motivation Never
b. Lack of
Motivation Sometimes
b. Lack of
Motivation Always
c. Caretaking
Issues
c. Caretaking Issues
Never
c. Caretaking Issues
Sometimes
c. Caretaking Issues
Always
d. Don't know
where to start
d. Don't know where
to start Never
d. Don't know where
to start Sometimes
d. Don't know where
to start Always
e. Family/Friends
do not support
e. Family/Friends do
not support Never
e. Family/Friends do
not support Sometimes
e. Family/Friends do
not support Always
f. No access to
facilities or
Equipment
f. No access to
facilities or Equipment
Never
f. No access to
facilities or Equipment
Sometimes
f. No access to
facilities or Equipment
Always
g. Alcohol Use
g. Alcohol Use
Never
g. Alcohol Use
Sometimes
g. Alcohol Use
Always
h. Tobacco Use
h. Tobacco Use
Never
h. Tobacco Use
Sometimes
h. Tobacco Use
Always
i. Health Issues
i. Health Issues
Never
i. Health Issues
Sometimes
i. Health Issues
Always
Other (please specify)
17. How would you rate your support system: or those people in your life who would encourage
you to make healthy lifestyle choices in your activity and diet?
Strong Support System
Somewhat Strong Support System
Somewhat Weak Support System
No Support System
18. Would you be interested in attending a 16 week clinic to become better educated on healthy
choicesand making lifestyle changes?
Not interested
Somewhat interested
Very interested
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19. Which topics would be most beneficial to you during in a 16 week clinic on healthy living
and weight loss?

Not Beneficial Slightly Beneficial
Somewhat
Beneficial
Very Beneficial
a. Aging
*Which topics
would be most
beneficial to you
during in a 16
week clinic on
healthy living and
weight loss? a.
Aging Not
Beneficial
a. Aging
Slightly Beneficial
a. Aging
Somewhat
Beneficial
a. Aging Very
Beneficial
b. Body
Composition
b. Body
Composition Not
Beneficial
b. Body
Composition
Slightly Beneficial
b. Body
Composition
Somewhat
Beneficial
b. Body
Composition Very
Beneficial
c. Cholesterol
c. Cholesterol
Not Beneficial
c. Cholesterol
Slightly Beneficial
c. Cholesterol
Somewhat
Beneficial
c. Cholesterol
Very Beneficial
d. Cooking
d. Cooking
Not Beneficial
d. Cooking
Slightly Beneficial
d. Cooking
Somewhat
Beneficial
d. Cooking
Very Beneficial
e. Diet
e. Diet Not
Beneficial
e. Diet
Slightly Beneficial
e. Diet
Somewhat
Beneficial
e. Diet Very
Beneficial
f. Diabetes
f. Diabetes
Not Beneficial
f. Diabetes
Slightly Beneficial
f. Diabetes
Somewhat
Beneficial
f. Diabetes
Very Beneficial
g. Exercise
g. Exercise g. Exercise g. Exercise g. Exercise
Not Beneficial Slightly Beneficial Somewhat
Beneficial
Very Beneficial
h. Heart Disease
h. Heart
Disease Not
Beneficial
h. Heart
Disease Slightly
Beneficial
h. Heart
Disease Somewhat
Beneficial
h. Heart
Disease Very
Beneficial
i. High Blood
Pressure
i. High Blood
Pressure Not
Beneficial
i. High Blood
Pressure Slightly
Beneficial
i. High Blood
Pressure
Somewhat
Beneficial
i. High Blood
Pressure Very
Beneficial
j. Muscular
Strength
j. Muscular
Strength Not
Beneficial
j. Muscular
Strength Slightly
Beneficial
j. Muscular
Strength
Somewhat
Beneficial
j. Muscular
Strength Very
Beneficial
k. Smoking
Cessation
k. Smoking
Cessation Not
Beneficial
k. Smoking
Cessation Slightly
Beneficial
k. Smoking
Cessation
Somewhat
Beneficial
k. Smoking
Cessation Very
Beneficial
l. Stroke
l. Stroke Not
Beneficial
l. Stroke
Slightly Beneficial
l. Stroke
Somewhat
Beneficial
l. Stroke Very
Beneficial
Other (please specify)