Weigh Beyond Registrations & Pre-Program Assessment
Hello and welcome to Weigh Beyond! Please take a few minutes of your time to provide registration information and to answer the questions below. These questions will be asked at the beginning and the end of the program and will help us better understand the behavior change that occurs during the program. Thank you!
Name
*
First Name
Last Name
Email
*
example@example.com
Work location
Please Select
Collegeville
Houston
Lake Jackson
Midland
Other
Are you on a Dow health plan?
Yes
No
Date of birth
*
-
Month
-
Day
Year
Date
What is your gender?
Female
Male
Non-Binary
Prefer not to answer
How tall are you?
*
How much do you weigh?
*
Which statement best describes your physical activity level in the past two months?
*
I don’t walk/exercise regularly and don't plan to start
I don't walk/exercise regularly but I've been thinking about starting
I'm active but do not have any planned exercise time
I exercise a few days a week but could be doing more
I get the recommended 150 minutes of exercise each week
Which statement best describes your diet of whole grains, fruits, veggies and lean protein in the past two months?
*
I do not eat a diet with any of those foods and am not planning to start
I have been thinking about starting to eat a diet containing these foods
My diet has these foods but not at every meal
The majority of my meals have all these food groups
Every meal I eat has the recommended servings of whole grains, fruits, veggies and lean protein
In the past 2 months, on average how many times did you have fast food each week?
*
0
1-2
3-5
6+
On average, how many hours of sleep do you get each night?
*
Please rate your average stress level.
*
Never Stressed
1
2
3
4
Always Stressed
5
1 is Never Stressed, 5 is Always Stressed
How often do you do each the following?
*
Never
Sometimes
Frequently
Always
Meal planning
Exercise planning
Healthy goal setting
Track your activity
Track your food
Drink soft drinks or other sweetened beverages?
Consider if what you're eating is healthy
Consider if you're eating because you're hungry or for another reason
Submit
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