TBCGF Inc. Health & Wellness Questionnaire

TBCGF Inc. Health & Wellness Questionnaire

Your answers help tailor and track outcomes of TBCGF Inc. programs like Ready 5K and Ask a Practitioner series. Responses are optional and remain confidential.
*Demographic Information*
Year of birth
YYYY
Gender assigned at birth

MaleFemale
*Health Status*
How would you describe your current health status?

ExcellentGoodFairPoor
Do you have any known health conditions?

Heart DiseaseDiabetesHypertension (High blood pressure)AsthmaCancerChronic kidney diseaseLiver diseaseObesityOther
Please provide a brief overview of your medical history
Have you undergone any major surgeries?

YesNo
If yes, list them if you feel comfortable.
*Healthcare Provider Information*
Do you have a primary care provider?

YesNo
If so, how frequently do you see your healthcare provider?

More than twice a monthOnce a monthEvery other month4 to 6 monthsEvery 6 months6 to 12 monthsYearlyI have not been seen in more than 2 yearsOther
*Medications & Dietary Habits*
Do you regularly take medications or supplements?

MedicationSupplementsMedication & supplementsNo, I do not take either
On average, how many meals per week do you typically consume outside of your home?

1 to 23 to 56 or moreI prepare all of my meals at home
How often do you include fruits and vegetables in your diet?

Every mealAt least one meal per dayA few meals a weekI do not like fruits or vegetables
Are you currently prescribed a GLP-1 medication (For example: Ozempic, Wegovy, Semaglutide, Mounjaro, Tirzepatide, or others for weight loss management)?

YesNo
Have you previously participated in any weight loss or health program?

YesNo
If yes, please briefly describe your experience.
*Physical Activity Levels & Motivation*
How many days per week do you currently engage in physical activity for at least 30 minutes (e.g., walking, jogging, or other exercise)?

0 days1-2 days3-4 days5 or more days
On a scale of 1 to 10, how confident do you feel about completing a 5K race or walk (1 = not confident at all, 10 = extremely confident)?
How knowledgeable do you feel about proper nutrition and hydration strategies to support physical activity

Not knowledgeable at allSomewhat knowledgeableVery knowledgeable
What challenges, if any, prevent you from engaging in regular physical activity? (Select all that apply)

Lack of timeLack of motivationHealth concerns or physical limitationsLack of access to safe spaces for exerciseOther
How long does it currently take you to walk or jog one mile (if applicable)?

I have not attempted this beforeOver 20 mins15-20 minutes10-15 minutesUnder 10 minutes
*Health Education Interest*
Would you be interested in learning more about managing your health through nutrition, exercise, and lifestyle changes?

YesNo
Which areas of health education would you find most beneficial?

Understanding lab resultsGrocery shopping for optimal healthMeal planningReducing heart disease riskOther
Consent:

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand this information will assist the practitioner in developing the most effective educational program for participants who complete this questionnaire.

Thank you for your input, and we look forward to creating high-quality programming together.
Email
Although not necessary, please provide your best email for continued and specialized communication.
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TBCGF Inc. Health & Wellness Questionnaire

*Demographic Information*

*Health Status*

*Healthcare Provider Information*

*Medications & Dietary Habits*

*Physical Activity Levels & Motivation*

*Health Education Interest*

Demographic Information

Health Status

Healthcare Provider Information

Medications & Dietary Habits

Physical Activity Levels & Motivation

Health Education Interest