Height: feet inches
Marital or partner status:
Highest educational degree:
Estimated household income:
How did you hear about this survey?
Phone number (please include area code):
In order to
protect your confidentiality, we will separate your name and contact
information from the rest of this survey and store it in a
different database. You will be identified only by a
participant number in the main database.
THE FOLLOWING QUESTIONS IN RELATION TO THE HEALTH PRACTICE YOU LISTED:
1. Please provide a brief description of how you engage in
this practice in a typical week (e.g., how many times per
2. When did you begin to engage in this practice
3. What motivated you to start?
4.Were there any times in which you stopped doing
the practice but started up again? If so, how were
you able to
begin it again?
5. What motivates you to do the practice now?
6. On a scale from 1 to 10, where 1= not at all enjoyable
and 10 =
extremely enjoyable, how enjoyable do you find engaging in
7. What are the obstacles to you engaging in
7a. How do you overcome these
8. What supports you in engaging in this practice?
9. On a scale from 1 to 10, where 1= not at all confident
and 10 =
extremely confident, how confident are you that you will continue to
engage in this practice in the future?
Any other comments?