In the past 7 days, how many days did you engage in physical activity that increased your heart rate (e.g., brisk walking, running, swimming)?

On the days that you engaged physical activity that increased your heart rate, for how long did you exercise (in minutes)?

How intense was your typical exercise?

Briefly describe the kinds of leisure-time physical activity you engage in, or type N/A.

You can type things like brisk walking, jogging, swimming, soccer, yoga, hiking, or any other leisure-time physical activities.

On average, how many days a week do you engage in strength training?

In the past 7 days, how many servings of fruits did you typically eat each day? (1 serving = 1 medium piece of fruit or 1 cup of fruit (the size of a baseball)

In the past 7 days, how many servings of vegetables did you typically eat each day? (1 serving = 1 cup of fresh vegetables or 1⁄2 cup of cooked vegetables)

In the past 7 days, how many servings of high fiber or whole grain foods did you typically eat each day? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal, 1⁄2 cup of cooked cereal such as oatmeal, or 1⁄2 cup of cooked brown rice or whole wheat pasta.)

In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day? (Examples include fried chicken, fried fish, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese, or mayonnaise.)

In the past 7 days, how many sugar-sweetened (not diet) beverages did you typically consume each day?

In the past 7 days, how many days did you drink alcohol?

On the days that you drank alcohol, how many alcoholic drinks did you have?

Each night, how many hours of sleep do you usually get?

If your blood pressure was checked within the last two months, what was it when it was last checked?

If your cholesterol was checked within the last two months, what was your total cholesterol when it was last checked?

If your glucose was checked in the last two months, what was your fasting blood glucose (blood sugar) level the last time it was checked?

If you have had your hemoglobin A1c level checked in the last two months, what was it the last time you had it checked?

If you have had an an oral glucose tolerance test within the last two months, what was it when it was last checked?

Please rate from 0 (cannot do at all) to 10 (highly certain can do) how certain you are that you can reach your personal health goals while in Transform.

Think of your work experiences over the past 4 weeks (28 days). In the space provided below, type the number of entire work days missed because of problems with your physical or mental health. (Please include only days missed for your own health, not someone else’s health.)

How many times did you visit a doctor, emergency room, or clinic for urgent care treatment (for example, because of new symptoms, an accident, or something else unexpected) in the past 12 months? Include only visits regarding your own health, not visits when you took someone else to be examined.

How many nights did you stay in a hospital during the past 12 months (not including nights associated with childbirth)?

On a scale from 0 to 10 where 0 is the worst job performance anyone could have at your job and 10 is the performance of a top worker, how would you rate your overall job performance on the days you worked during the past 4 weeks (28 days)?

Comments about your experience so far in Transform: