Healthy Eating Active Living 2024

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The HEAL program is designed for people in the community who are committed to changing their lifestyle.

Email *

First and Last Name *

Phone Number *

Email address *

Birthday *

YYYY

Weight *

Height *

Exercise Level *

I have never exercised

Very beginner

Beginner ( I have some experience with exercise but still consider myself a beginner)

Intermediate (I feel comfortable performing a wide range of exercises)

Advanced ( I am comfortable in a gym or home with all exercises)

I can get down to the floor and stand back up comfortably *

yes

Nutrition Knowledge *

Why are you interested in joining this program? *

What is your main goal/ what you would like to take away from this program?

weight loss

nutrition knowledge

Fitness

improve my overall health

Do you currently suffer from any chronic diseases? *

Do you smoke? *

yes

Have you struggled from addiction before? *

Yes

Have you/ do you struggled with an eating disorder? *

yes

If answered yes to either of above please elaborate?

How would you evaluate your overall health? *

In good physical health (no illness or diabetes)

Mildly physically impaired (minor illness or disabilities)

Moderately physically impaired (requires substantial treatment)

Severely physically impaired (required extensive treatment)

Totally physically impaired (confined to bed)

Have money or available resources prevented you from getting the services you require?

yes

Clear selection

Thank you!

Thank you for filling out this survey. There is limited space available and you will be receiving an email and/or phone call with details regarding this program.

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