Pre-Assessment Survey

Transcription

1 Date: Participant ID: Tripler/Schofield Barracks MTF: Pre-Assessment Survey Directions: Please use a blue or black pen to complete this survey. Be sure to darken bubbles completely. Do not use checks or x s or special characters to fill in the bubbles. Please be sure to write legibly where a written answer is required. Demographic and Weight Status Information 1. Age: years 2. Gender: 1 Male 2 Female 3. Status: 1 Active Duty 2 USAR 3 NG 4 N/A 4. Rank: 1 E1-E3 2 E4-E6 3 E7-E9 4 W1-W N/A 5. I am currently : 1 Single 2 Married 6. I live in: 1 Barracks 2 On-post housing 4 Off-post housing Civilian (Economy) 3 Off-post housing (Gov Quarters) 7. Height: inches 8. Current Weight: pounds 9. Waist circumference: inches 1 I don t know my waist circumference 10. Have you had an injury that has limited your physical activity in the last six months? Circle: Yes No 11. How did you first learn about Fit For Performance? 1 Commander 2 Healthcare Provider 3 Marketing tool (i.e. brochure, newsletter, flyer) 4 Friend, Spouse, Coworker 5 Other (Please specify: ) 12. Are you currently on the Army Body Composition Program per AR 600-9? 1 Yes 2 No 3 Unsure 13. Which statement describes your participation in the Fit For Performance program? 1 I am a voluntary participant. 2 I was command directed to participate. 1 1 Feb2016_Pre

2 14. What are your reasons for participating in Fit For Performance? Select all that apply. 1 Administratively placed on the Army Body Composition Program 2 Lose weight 3 Meet body fat standards 4 Maintain current weight 5 Improve Well-Being/ Feel better 6 Improve Medical Condition (i.e. high cholesterol, high blood pressure, diabetes) 7 Other (Please explain: ) 15. What is your goal weight in pounds? pounds 16. What is your preferred teaching style method? 1 Face to Face Group session 2 Face to Face Individual Session 3 Internet (i.e s) 4. Mobile Phone Applications (i.e. text messages) Current Physical Activity and Dietary Practices 17. Which sentence best describes your dietary/eating habits? 1 I do not intend to make dietary changes to lose weight. 2 I intend to make dietary changes to lose weight at some point (more than 30 days) in the future. 3 I intend to make dietary changes to lose weight within the next 30 days. 4 I have made dietary changes to lose weight (less than six months ago). 5 I have maintained dietary changes to lose weight for at least six months. 18. What are some current lifestyle habits and/or conditions that you think may be contributing to your weight? Select all that apply. 1 Poor eating habits 2 Limited access to healthy food 3 Inadequate physical activity 4 A temporary or permanent profile that significantly limits my physical activity 5 Inadequate sleep 6 Medications 7 OStress 8 Other, please specify: 2 1 Feb2016_Pre

3 19. What dietary changes are you currently practicing to help lose weight? Select all that apply. 1 Portion control / watching how much I eat 2 Making healthier food and beverage choices (i.e. more fruits/vegetables, fewer sweets/sweetened beverages) 3 Eating only when physically hungry 4 Control emotional eating / stress eating 5 Increasing water intake 6 Decreasing alcohol intake 7 Stopped skipping meals 8 Stopped binge eating 9 Increasing physical activity 10 Other, please specify 11 At this time, I am not practicing any dietary changes to lose weight. 20. Which sentence best describes your physical activity? 1 I do not intend to make changes to my level of physical activity. 2 I intend to make changes to my level of physical activity at some point (more than 30 days) in the future. 3 I intend to make changes to my level of physical activity within the next 30 days. 4 I have made changes to my level of physical activity (less than 6 months ago). 5 I have maintained changes to my level of physical activity to lose weight for at least 6 months. 21. Currently, how many days per week do you participate in moderate intensity level physical activities for at least 10 minutes at a time? Moderate intensity level physical activities include physical activities that cause light sweating and a slight to moderate increase in breathing or heart rate like brisk walking, bicycling, and gardening. Please fill in your response: days per week If none, skip to question On the days when you do moderate intensity level activities for at least 10 minutes at a time, on average, how much total time per day do you spend doing these activities? minutes minutes minutes 4 60 minutes or more 3 1 Feb2016_Pre

4 23. Currently, how many days per week do you participate in vigorous intensity level physical activities for at least 10 minutes at a time? Vigorous intensity level physical activities cause heavy sweating and large increases in breathing or heart rate. Examples of vigorous activities are running, aerobic classes, heavy yard work, and briskly swimming laps. Please fill in your response: days per week If none, skip to question On the days when you do vigorous intensity level activities for at least 10 minutes at a time, on average, how much total time per day do you spend doing these activities? minutes minutes minutes 4 60 minutes or more 25. If you own and/or utilize a fitness tracker, what is your average step count per day? 1 I do not own or utilize a fitness tracker 2< 10,000 steps / day 3 10,001 15,000 steps / day 4 > 15,001 steps / day 26. How confident or unconfident do you feel that you will be able to make nutritional changes in order to lose weight? 1 Completely unconfident 2 Unconfident 3 Neutral 4 Confident 5 Completely confident 6 NA. I do not need to make any nutritional changes 27. How confident or unconfident do you feel that you will be able to make physical activity changes in order to lose weight? 1 Completely unconfident 2 Unconfident 3 Neutral 4 Confident 5 Completely confident 6 NA. I do not need to make any physical activity changes 4 1 Feb2016_Pre

5 Knowledge 28. In order to change my eating and physical activity behavior, it is important to keep track of everything I eat and drink, as well as, the amount of physical activity I do each day. 29. All fats are high in calories. 30. Skipping breakfast is a successful weight loss strategy, as long as I follow a healthy diet. 31. All fats are unhealthy and should be avoided. 32. Weight loss plateaus (times when it is difficult to lose any more weight) are common. 33. Once a weight loss goal is met it is no longer necessary to employ self-monitoring tactics (monitoring weight, food and activity logs, etc ) 34. A good indicator of disease risk can be waist measurement. 35. How much activity should you get on most days of the week to maintain weight loss? minutes minutes minutes 36. How much of your plate should be fruits and vegetables for a healthy meal? 1 One quarter (1/4) 2 One half (1/2) 3 Three quarters (3/4) 5 1 Feb2016_Pre

6 37. What is your exercise intensity if you can talk (but not sing) while exercising? 1 Low intensity 2 Moderate intensity 3 Vigorous intensity Preferences 38. What are the best days of the week for you to participate in Fit For Performance group sessions? 1 Monday 2 Tuesday 3 Wednesday 4 Thursday 5 Friday 39. What is the best time(s) of day for you to participate in Fit For Performance group sessions? 1 Early morning 2 Late morning 3 Afternoon 4 Early evening 5 Late evening 6 1 Feb2016_Pre