About You     Name* Telephone Address Mobile   Email* Postcode D.O.B   Employment / Education     Employed (Manual) Employed (Non Manual) Umemployed Full Education House wife / Husband Retired       About your Lifestyle     Are you a smoker?     yes Used to Never   If you are a smoker have you tried to quit using any of the following Will Power Patches Zyban Hypnosis Other         How many portions of Fruit and Vegetables do you eat in an average day? None One or Two Three or Four Five or more         What would encourage you to eat more Fruit and vegetables? Lower Cost More Readily Available Greater Variety Nothing Other   How many times a week do you take part in structured activity (eg Gym, sport, jogging, walking etc) None One or Two Three or Four Five or more         Why do you exercise? (Please tick as many as you wish) Get fit Lose weight Feel good Look good Build muscle Competition Have fun Socialise         If you do not exercise regularly, why is this? (Please tick as many as you wish) Can't afford to Not interested No time Not sporty type Don't know when/where the activities are held Activities on offer Do not appeal to me         What local activity would help you lead a healthier lifestyle           Would you like to be added to our mailing list. You will only be sent information on the healthy Lifestyle Programme and it's events and activities. Yes No THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE. IF YOU HAVE CHOSEN TO SUBMIT YOUR NAME AND ADDRESS YOU WILL BE ENTERED INTO A MONTHLY PRIZE DRAW WHERE YOU CAN WIN FREE TOTAL FITNESS GYM MEMBERSHIP. Mike Parker Healthy Lifestyle Manager