Survey

Upper Room Christian World Center's Open Arms Women's Ministry is preparing to launch a new Total Wellness Initiative. By filling out the following short survey, you are helping us to mold this program to be the best it can be.

Your Information

* First Name

* Last Name

* Phone Number

* Zip Code

Email Address

Check here if you do not use email:

No email

* Select your age range:

Program Survey

* What would you like to get out of your customized wellness program?

* Have you tried any other diets before?

Yes

No

If yes (Check all that apply)

* How would you rate your physical activity / exercise level?

Sedentary (No exercise)

Light (occasional sporadic exercise / activity)

Moderate (1 - 3 days a week of regular exercise / activity)

Active (4 - 6 days a week of regular exercise / activity)

Sometimes, I'm at different stages

* Which of the following contribute to your fitness level? (Check all that apply)

If "injury" is selected above, please explain below: (If not, please skip this)

* Which physical activities / exercises most interest you? (Check all that apply)

* Which of the following contribute to your nutritional life style? (Check all that apply)

If "sickness" is selected above, please explain below: (If not, please skip this)

* What wellness topics are you interested in? (check all that apply)

Are there any other comments or recommendations that you would like to see implemented in our wellness program? (Please include below)

0/500 words

Would you like to be involved?

Do you have any professional background in any area of health and wellness and would like to offer your services to help in implementing the Open Arms Wellness Initiative?

Yes

No, thanks

If yes above, please answer the following:

Area(s) of Expertise

Time Availability

* Indicates Response Required

Lose a Lot of Weight (more than 20 lbs)	Lose Some Weight (less than 20 lbs)
Maintain Current Weight	Increase Strength
Increase Endurance (Cardiovascular / Heart Health)	Improve Overall Health
Improve Mental and Emotional Wellness	Spiritual Well Being
Increase Knowledge in Nutrition and Fitness	Increase Motivation
Other

Aerobic Dancing	Power Walking	Swimming
Bicycling	Playing Sports	Running
Elliptical	Weight Training	Kickboxing
Stepping	None	Other

Exercise / Fitness	Nutrition
Weight Loss	Cardiovascular (heart health)
Skin Health	Sleep
Women's Health	Emotional and Mental Health
Chronic Diseases (ongoing)	Communicable Diseases (transferrable one to another)
Physical Injury and Prevention	Spiritual Weakness
Other