Pre Survey

The Lac qui Parle Health Network is three independent rural health care facilities collaborating to ensure coverage of quality healthcare for your region

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Pre-Survey

This survey will be taken at the beginning and end of the program.
Survey data will be used to determine if the program encourages participants to increase healthy behaviors.

* Indicates required field

Gender? *

Male Female

What is your age? *

21-30 31-40 41-50 51-60 over 61 Prefer not to say

Employment Category? *

Full time Part Time Temporary

How oftern do you currently exercise? *

0 days per week 1-2 days per week 3-4 days per week 5-6 days per week 6-7 days per week

When you exercise, how many minutes per day does your exercise total? *

10 minutes 20 minutes 30 minutes 60 minutes if >60 minutes, ________# of minutes

Please check all that apply. Do you on average (daily): *

Sleep at least 6 hours Drink at least 32 oz. of water Eat 3-5 fruits & vegetables Eat a home cooked meal Brush your teeth Floss your teeth Compliment someone

Please check all that apply. Do you on average (daily): *

Smoke Drink 2 or more pops Consume 2 or more alcoholic beverages None of the above

Submit

Contact Us

Bernice Robinson - LqPHN Executive Director
900 Second Avenue
Madison, MN 56256
320-698-7199 ext. 7110
brobinson@lqphnmn.org

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