General Questionnaire & Assessment

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General Questionnaire & Assessment

Bolo Code exists to equip you with acute awareness, physical capabilities, and self-protection skills. To better understand you, your current skill level, and self-defense/fitness goals, please take 5-6 minutes to complete this form. Sections are divided into 'Demographic Information', 'Self-defense' (disclaimer: this section may be triggering for some), and 'Fitness'. Some sections may be skipped depending on your responses.

Language

English (US)

1
Age* This field is required.
18-24
25-34
35-44
45-54
55+
I prefer not to answer.
2
Current City (i.e. Dallas, TX)
3
Gender* This field is required.
Man
Woman
Transgender man
Transgender woman
Non-binary/gender nonconforming
I prefer not to answer.
4
Ethnicity* This field is required.
Black/African origin
South Asian
East Asian
Pacific Islander
Mexican-American/Chicano
Latinx/Latin origin
Hispanic/Spanish origin
White/Caucasian
American Indian
Alaskan Native
Native Hawaiian
Middle Eastern
Caribbean
Two or more ethnicities
A different ethnicity or origin
I prefer not to answer
5
Marital Status* This field is required.
Single
Living with partner
Married
Separated
Divorced
Widowed
I prefer not to answer.
6
Do you live with anyone?* This field is required.
Live by myself
With roommates
With partner/spouse
With parents
I prefer not to answer.
7
What type(s) of training are you interested in?* This field is required.
Self-defense, martial arts
Tactical conditioning, fitness
Both
8
Have you ever felt threatened, compromised, or in fear for your life?* This field is required.Your safety and identity is completely confidential and will never be shared.
I've been stalked; I am being stalked.
I've been ambushed/attacked.
Nothing happened, but I had a gut feeling that something was wrong.
I've been in an abusive relationship; I am in an abusive relationship.
I prefer not to answer.
Never
9
Have you ever taken a PTK-SMF class or enrolled in a PTK-SMF program?* This field is required.
YESNO, what is PTK-SMF?!
10
Have you ever taken a self-defense class or enrolled in a self-defense program (not PTK-SMF)?* This field is required.
YESNO
11
Have you ever taken a self-defense class or enrolled in a self-defense program?* This field is required.
YESNO
12
If so, what system(s) or martial art(s)? *NOT Kickboxing
General
Boxing/MMA
Jiu Jitsu/Wrestling/Grappling
Muay Thai
Knife Defense/FMA (Filipino Martial Arts)
Krav Maga
Tae Kwon Do
Karate
Aikido
13
Please answer the following to the best of your ability!* This field is required.Please make sure you've selected each slider before proceeding to the next question.
I feel safe walking alone at night.
I feel confident in defending myself in a hand-to-hand/fist fight or ambush.
I feel confident in defending myself from the ground.
I feel confident in defending myself against a knife or other weapon.
I feel confident in defending myself against multiple opponents.
It is necessary to have self-defense training.
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
I feel safe walking alone at night.
I feel confident in defending myself in a hand-to-hand/fist fight or ambush.
I feel confident in defending myself from the ground.
I feel confident in defending myself against a knife or other weapon.
I feel confident in defending myself against multiple opponents.
It is necessary to have self-defense training.
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
Disagree
Somewhat Disagree
Somewhat Agree
Agree (Nobody can mess with me!)
14
Do you carry a self-defense/personal safety tool on your person? Select all that apply.* This field is required.
Firearm
Edged/impact weapon (knife, pepper/OC spray, flashlight, pen, etc.)
None
I carry a self-defense/personal safety tool in my bag/purse.
I carry a stick when I go for a walk.
I prefer not to answer
15
Are you interested in learning how to effectively use your preferred self-defense/personal safety tool?* This field is required.
YesNo
16
What has stopped you from pursuing self-defense training? Select all that apply.* This field is required.
Time
Motivation
Anxiety/nervousness (I don't want to be seen as the "rookie"; I don't feel comfortable with a group of people)
Past trauma
Finances
Lack of training opportunities/offerings
Location
I prefer not to answer
17
In your opinion, how much time do you need to spend developing your self-defense and personal protection skills to feel safe?* This field is required.
< 1 hr/week
1-3 hrs/week
4-6 hrs/week
7-9 hrs/week
9+ hrs/week
18
Realistically, how many days a week can you commit to your self-defense and personal protection training?* This field is required.
1 day/week
2-3 days/week
4+ days/week
19
What are your most burning questions about self-defense/personal protection, if any?
Huge
Large
Normal
Small
Ok
Ok
20
How much is your self-defense/personal protection worth to you per month?* This field is required.
< $75
$75-100
$101-125
$126-150
$151-175
$175+
21
How much is your self-defense/personal safety worth to you per session?* This field is required.
$10-25
$26-50
$51-75
$76-100
$100+
22
What is your learning style? Select all that apply.* This field is required.
Reading
Listening
Watching
Practicing
23
What motivates you most to get self-defense training? Select your top 3.* This field is required.
To protect myself
To protect loved ones
I want to fight somebody!
To learn self-defense laws
To feel safe when I travel
To get a good workout
24
How often do you workout?* This field is required.
0 days/week; every now and then!
1-2 days/week
3-4 days/week
5+ days/week
25
How much time do you spend per workout session?* This field is required.
< 30 min.
30-60 min.
60+ min.
26
What do you think your current fitness level is?* This field is required.
Beginner
Intermediate
Advanced
27
Where do you workout? Select all that apply.* This field is required.
Gym
Group classes
Home
Workout videos
Personal trainer
Outdoors/park
28
What are you biggest challenges when it comes to your fitness and wellness goals? (i.e. I struggle with nutrition; I don't know where to start, etc.)* This field is required.
Huge
Large
Normal
Small
Ok
Ok
29
How much are your fitness and wellness goals worth to you per session?
$10-25
$26-50
$51-75
$76-100
30
What type(s) of workouts are you most likely to commit to? Select your top 3.* This field is required.
HIIT (High intensity interval training)
Cardio/aerobic
Strength training/anaerobic
Low impact
Mixed in with self-defense/fight sequences
31
What type(s) of equipment do you use? Select all that apply.* This field is required.
None; bodyweight
Resistance bands
Dumbbells
Kettlebells
Clubbells
Gym machines
Barbell/squat rack
Workout bench
Strength sliders
Punching bag
32
What motivates you most to workout? Select your top 3.* This field is required.
Build muscle; strength gains
Cardio; aerobic gains
Weight loss
Flexibility
Mobility
Tone up
Agility
33
Any other activities you enjoy?i.e. hiking, cycling, basketball, dance, etc.
Huge
Large
Normal
Small
Ok
Ok
34
Would you like to see private or group trainings offered?* This field is required.
Private
Group
Both
35
Would you like to see private or group trainings offered? Select all that apply.* This field is required.
Private
Group
Womxn only
LGBTQ+ only
BIPOC only
36
Would you like to see virtual or in-person trainings offered? Select all that apply.* This field is required.
Virtual (real time)
In person (Dallas/Fort Worth Metro ONLY)
Virtual (pre-recorded videos)
37
If you were to enroll in a program, what is your general availability?(i.e. Mondays 6-9pm; Tuesdays and Thursdays 2-4pm; etc.)
Huge
Large
Normal
Small
Ok
Ok
38
Are you interested in being part of a small, private online community that provides resources and moderated discussions around personal safety and tactical fitness conditioning?
YESNO
39
Name* This field is required.
First Name
Last Name
40
Email* This field is required.
example@example.com
41
Please verify that you are human* This field is required.
Should be Empty:

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