Upon submission you will be taken to our registration page to create your username and password.
Primary Member Name (req.)
Primary Email Address (req.)
Address of Household (req.)
Names of Members of Household
The information you share is strictly private, protected by HIPPA regulations. It is used for the purpose of showing progress on LIFE membership health initiatives to provide aggregate data as required by our grant funding partners.
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs or carrying groceries? (req.)
Please Select:8. Completely9. Mostly10. Moderately11. A little12. Not at all13. Refused14. Don’t know
In the past 7 days, how would you rate your fatigue on average? (req.)
Please Select:15. None16. Mild17. Moderate18. Severe19. Very severe20. Refused21. Don’t know
Indicate the number of meals you eat away from home during a week: (req.)
Please Select23. Zero24. One to three25. Four to six26. Seven or more
On an average day, how many servings of vegetables and fruits do you eat? (req.)
Please Select27. Zero28. One to three29. Four to six
On an average day, indicate which drink you consume the most? (req.)
Please Select:30. Milk/Dairy Drinks31. Water17. Moderate32. Coffee/Tea33. Soda/Energy Drinks/Fruity or Sports Beverages34 Juices35. Alcohol/Beer/Wine
How many times do you exercise for a minimum of 30 minutes in a week? (req.)
Please Select36. None37. One to three times38. Four or more times39. Everyday
What type of exercise do you participate in most often? (req.)
Please Select40. Walking41. Jogging/Running42. Weight Lifting/Strength Training/Gym Fitness43. Swimming44. Classes ie; yoga, dance, Pilates etc.45. Bicycling
Other forms of exercise?
How many hours during an average night, do you get a good/restful sleep?(req.)
Please Select47. 1-3 hours48. 4-6 hours49. 7-8 hours50. more than 8 hours
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Thank you for completing our survey. Your information is HIPPA protected, all data is aggregated so no personal information is attached to it - no worries!
Your survey is valuable to us because it will be combined into a community health report card.
Our report card allows us to show our grant funders that we are making progress and their investment is contributing to important work.
Better report cards mean more opportunities to enjoy healthy living!