Get Fit, Lose It Pre-Survey Tool
Welcome to the Get Fit, Lose It series!

Before beginning the program, please take a moment to complete this brief survey. You will be asked to complete this survey again at the end of the last class. By taking this survey at the beginning and the end of the program, you will be able to see your progress towards a healthier lifestyle.

The survey is scored on a scale of 0-13 points. You'll receive 1 point for each answer that meets the criteria for a healthy lifestyle. For example, if your score is 7 out of 13 points you are currently a little more than halfway to complete adherence to a healthy lifestyle.

Sign in to Google to save your progress. Learn more
Your Name (First Name & Last Name) *
Which NC County do you live in (i.e. Person, Granville, etc.)? *
Are you Hispanic or Latino?
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What is your race?
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What is your sex?
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On a scale of 1 to 10, how healthy do you consider yourself? (1=poor, 10=best)
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What is your weight? (in pounds)
What is your height? (in feet, in inches)
What is your waist circumference? (in inches)
(Stand up to get an accurate waist measurement. Wrap the tape measure around the widest part of your stomach, across your belly button. Breathe in gently and then take the measurement on the exhale.)
What is your blood sugar? 
What is your A1C? (at your last doctor's appointment)
What is your cholesterol?
What is your blood pressure?
Do you have any chronic conditions/diseases?
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