BeFitMe Survey

Please answer each question. You can use the Reset button if you need to start over.

What is your gender? Male Female

How tall are you?

Feet

Inches

Change in weight

Current weight

Weight 1 year ago

No change in weight

Did you have intentional weight loss, for example due to dieting or exercise? Yes No

In the last week, how often did you feel that everything you did was an effort? None of the time Some or a little of the time (1-2 days) A moderate amount of the time (3-4 days) Most of the time (>4 days)

In the last week, how often did you feel that you could not get going? None of the time Some or a little of the time (1-2 days) A moderate amount of the time (3-4 days) Most of the time (>4 days)

During the past two weeks, have you walked for exercise? Yes No

During the past two weeks, have you done moderately strenuous household chores like scrubbing or vacuuming? Yes No

During the past two weeks, have you done any gardening? Yes No

During the past two weeks, have you done any general exercise, excluding walking? Yes No

During the past two weeks, have you mowed a lawn? Yes No

During the past two weeks, have you done any golfing? Yes No

Have you had any recent pain or acute flare-up in your dominant wrist or hand from conditions like arthritis, tendonitis, or carpal tunnel syndrome? Yes No

Have you had any surgery on your dominant hand or arm during the last 3 months? Yes No