Name of Team:
City/Town of Team:
Company:
Physical activities away from
work
At what time of the day did you
usually choose to exercise before the
Shape UP program?
Before I went to work
During my lunch break
After work or at night
I never could find time to exercise
At what time of the day did you
usually choose to exercise during Shape
Up?
Before I went to work
During my lunch break
After work or at night
I can't find time to exercise
What kind of physical activities did
you take part in before Shape UP?
(Check All that Apply)
Walking/Running/Aerobics
Lifting Weights/Calisthenics
Yoga/Pilates
Bicycling
Swimming
If other please specify
None
Of all the activities you did, which
one did you find the most fun to participate in?
What king of physical activities
did you take part in during Shape Up? (Check All that Apply)
Walking/Running/Aerobics
Lifting Weights/Calisthenics
Yoga/Pilates
Bicycling
Swimming
If other please specify
None
Of all the activities you do now,
which one do you find the most fun to participate in?
Health Status
What would you say, in general, your
health was at the beginning of Shape Up?
Very Good
Good
Fair
Poor
What would you say in general
your health is now?
Very Good
Good
Fair
Poor
Demographics
Gender
Female
Male
What is your current
age?
less than 18
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
Which category(s)
were you entered in? (Check All that Apply)
Beginner Activity
Intermediate Activity
Experienced Activity
Professional Activity
Weight Loss
Personal Lifestyle
Achievements/Goals upon
Weight Loss Participants Only
Lost weight
Maintained current weight
Gained weight
Not applicable
If you lost or gained weight, about
how many pounds?
1-9 lbs
10-19 lbs
20-39 lbs
40 or more lbs
Not applicable
Personal Achievement for
Exercise/Physical Activity
During Shape Up, I:
exercised more/was more active
maintained current level of exercise/activity
exercised
less/ was less active
Personal Achievement for
Meals
During Shape Up, I:
(check all that apply)
Personal Goals: Overall
Health
At the Conclusion of Shape Up
please indicate, from the following statements, if you benefited.
More physically fit
Felt healthier
Had clothes fit better
I achieved/came close to my goals
I could workout longer than ever before
Felt better about myself overall
I was toned/slimmer
Prevented or lessened health problems
other:
Motivation for staying
focused on your goals - What factors during
Shape Up made it
easier for you to exercise and/or achieve your goals?
(Check all that apply)
Peers at work
Family members
Friends
Pedometer
Wanted to feel healthy
Wanted to lose weight
The exercises/personal challenges/articles that were provided
Didn't want to let down my team
Exercising with a teammate made it a lot easier
Other:
Satisfaction of Shape Up
What did you like the most/least about Shape Up in
2008?
What I liked the most was:
What I liked the least was:
What years have you participated
in Shape Up? (check all that
apply)
2003
2008
Did this program get you
excited about continuing to live a healthy lifestyle?
Yes
No
Were you pleased about the
results or difference Shape Up had on your life?
Yes
No
If "Yes" to the above question, please check all
that apply
I have more energy than ever before
I don't get tired when doing everyday things in my life like I
used to
I was able to quit or dramatically reduce drinking
I
was able to quit smoking
I have a new lease on life
Other
Do
you see yourself continuing to practicing healthy lifestyle habits?
Yes
No
Please share your
thoughts on Shape Up
If you see
potential growth for the Shape Up program within your company, please fill out the information
below. We will contact you to discuss how we can help!
Company Name
Contact Name
Email Address
Phone Number
Number of Employees
Thank You!
Please
complete and submit by Monday, April 30
