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.
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
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