If you are currently exercising, please tell us what type of activity you are currently participating in:

Vigorous Walking (Heart rate in moderate to high range)
Group Fitness Classes
Treadmill or other cardio equipment
Exercise at a fitness center
Running outdoors
Water Aerobics
Yoga
Exercise DVD/Videos at home
Other (please specify):

How often do you currently exercise?

5 times or more per week
3-4 times per week
1 -2 times per week
I exercise sporadically
I don't really exercise at all
I get out and walk at a face pace when weather permits

Do you feel you eat healthy (read labels, watch portion sizes, aware of calorie intake, get enough fruits and vegetables)?

Absolutely
Most of the time
I try, but have a hard time
No I don't eat healthy, but I would like to start
No I don't eat healthy and I don't plan to change
I am just not sure what I need to do to make healthier choices.
Other (please specify):

How many meals per week do you eat out?

1-2
2-3
4-5
More than 5

Do you feel your family eats healthy?

Yes
No
Not Sure

If you are currently not exercising, what type of activity do you think would get you active?

Please tell us how important these items are to you

	Very Important	Important	Not Important	Don't Care
My nutritional choices
Nutritional choices for my family
Getting enough personal physical activity
My family being active enough
Having exercise opportunities at school (classes, equipment, etc.).
Having healthy living information easily available

Would you join a fitness center at a reduced rate?

Yes
No

What time of day would be ideal for you to exercise?

Early morning before work
Right after work
5:00 p.m - 7:00 p.m
7:00 p.m - 9:00 p.m
Lunch time
Weekend mornings
Weekend afternoons
Weekend evenings
After 9:00 p.m
I don't think I will exercise regardless
Lunch time

When it comes to being aware or educated in regards to health and wellness I feel:

Informed, I feel I have many resources to turn to
Uninformed, I don't know where to get information
Uninformed, I don't have time to learn about it
Other (please specify):

What type of healthy living information would you like to have for yourself and to help you to educate your family and make healthy choices

Healthy Eating
Exercise Information
Family Physical Activity
Recipes
Disease Prevention (heart, diabetes, arthritis ,etc.)
How to stop smoking
Other (please specify)

Do you have any comments or suggestions in regards to the opportunities to making [TownName] a healthier community?

Healthy Living Questionnaire