Health Interest Questionnaire
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- Amy Bennett
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1 Page 1 of 7 Health Interest Questionnaire Thanks for telling us what health topics and activities would interest you (note: this questionnaire is intended for active and reserve military members and family members only). There are 13 questions in this survey demographics My age range is My gender is male female My duty status is active duty government civilian reservist family member Other
2 Page 2 of 7 My UIC is (please enter only the 5 or 6 digit alpha-numeric code for your command): Please write your answer here: Enter todays date * Please enter a date:
3 Page 3 of 7 preferences Where do you get physical activity most often? Home/neighborhood Fitness Center At work Other place Don t exercise by walking by biking Please indicate the best time for you to participate in Health Promotion/Wellness programs and activities Early AM Mid-AM Lunch Hour (mid-day) Late afternoon (1600 or later) Not at all Other How long should Health Promotion/Wellness programs and activities last? 30 minutes 45 minutes 60 minutes 90 minutes
4 Page 4 of 7 Which of these formats for Health Promotion/Wellness information would you be interested in? Pamphlets, magazines Videos, slide presentations Talks by experts Bulletin Boards/Kiosks Health Screenings/Health Fairs Classes and courses Participating in contests Television Internet GMT Friends app Yes Uncertain No What Health Promotion/Wellness topics are you most interested in learning more about? Tobacco Cessation Weight Management Basic Nutrition for Health Sports Nutrition Nutritional Supplements Healthy Cooking Family Health/Safety Cholesterol Control Hypertension (High Blood Pressure Control) Diabetes Control Physical Activity Stress Management Family Planning HIV prevention Prenatal/parenting Skills Back Injury Prevention Sports Injury Prevention Yes Uncertain No
5 Page 5 of 7 What is probability that you would participate in each of the following activities? Weight Training Yoga Massage Therapy (fee based) Walking Program Aerobic Exercise Kick Boxing Step Aerobics Jogging Cycling Body Fat Analysis Stress Management Course Healthy Cooking Class Group Weight Management Class Personal Trainer Sessions Tobacco Cessation Basic Nutrition Program Self-directed Computer Counseling Yes Uncertain No
6 Page 6 of 7 readiness Using the Answer Key below, determine your answer for each health behavior listed: 1 = I haven t really thought about improving this yet; 2 = I plan to improve this in the next 3-6 months; 3 = I plan to improve this within the next 30 days; 4 = I recently started doing this I have been working on this regularly for more than 6 months; 5 = I don t have this problem or this is N/A for me Practice healthy eating habits Maintain a good fitness program Reduce my stress Not smoke or use tobacco Lose weight, or maintain a healthy weight Reduce high cholesterol Reduce or manage my high blood pressure When was the last time you participated in a health and wellness class or activity during work hours or your lunch break? this year over one year ago over 5 yeras ago never
7 Page 7 of 7 Thank you! Submit your survey. Thank you for completing this survey.
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