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Go! GC Survey #1

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Would you say that in general your health is:

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Poor	0
Fair	0
Good	0
Very Good	0
Excellent	0

Which category best describes your diet right now

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Poor	0
Fair	0
Good	0
Very Good	0
Excellent	0

Activity level: (Choose One that fits best right now)

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I cannot exercise	0
Don’t currently have an exercise routine	0
I’m active but don’t have a dedicated exercise routine	0
Exercise at least 3 days per week	0
Exercise at least 5 days per week	0

Which categories best describe you:

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I am not able to effectively manage my chronic disease(s)	0
My chronic disease(s) are very difficult to manage	0
I have been diagnosed with pre-diabetes or another chronic disease and could use some help with management	0
I effectively manage my chronic disease(s).	0
I do not currently have any known chronic diseases (heart disease, diabetes, cancer, etc)	0

Most days of the week I have a positive outlook on my life and look forward to the future?

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Not at all	0
Slightly	0
Somewhat	0
Quite a bit	0
Most of the time	0

Do you have supportive relationships, at least one person you can depend on?

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Not at all	0
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Somewhat	0
Quite a bit	0
Most of the time	0

Do you feel valued as a person in most areas of your life?

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Quite a bit	0
Most of the time	0

Do you feel a sense of belonging in your community?

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Not at all	0
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Most of the time	0

Generally I have the financial resources I need to live a safe and healthy life.

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Not at all	0
Slightly	0
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Quite a bit	0
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My income range is

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Under $15,000	0
Between $15,000 and $29,999	0
Between $30,000 and $49,999	0
Between $50,000 and $74,999	0
Between $75,000 and $99,999	0
Between $100,000 and $150,000	0
Over $150,000	0

Do you have a doctor or primary care provider?

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Yes	0
No	0
Unsure	0

Age

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<18	0
18-24	0
25-34	0
35-44	0
45-54	0
55-64	0
65+	0

Overall, how would you rate the quality of your life?

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Poor	0
Fair	0
Good	0
Very Good	0
Excellent	0

Zip Code

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Height (feet)

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Height (inches)

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Weight (lbs)

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