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First Name
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Age
Gender
Male
Female
Major
How did you hear about this program?
Flier
Class Annoucement
Body Fat Table
Postcard
Health Iowa Staff
Student Health Staff Member
Friend
Website
Other
What is your current physical activity status?
Daily Activity (check one)
Little Daily Activity
Some Daily Activity (1 - 3 days/week)
Daily Activity (4 - 7 days per week)
Formal Exercise (check one)
Exercise < 1 per week
Exercise 1 - 2 days per week
Exercise 3 - 5 days per week
When it comes to taking steps to commit to leading a physically active lifestyle, I am:
Not yet ready to change
Thinking about changing
Ready to change
Making changes now
On Track
