Take the 3 vs 3 Pledge
Welcome to the 3 vs 3 Pledge! By participating, you are joining a community who are committing to three simple lifestyle changes that support better long-term health. Small changes can make a big difference. Thank you for completing this form. After you enter your information, we have 10 quick questions for you in order to get you started.
Email address
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example@example.com
First Name
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Last Initial
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Organization/Community You're Joining With (if applicable) or enter Self
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Preferred Follow-Up Method (We will send you a quick check-in at 30, 60, & 90 days)
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Email
Text Message
Through My Organization
I Will Check In Myself
Email
Mobile number
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Do you know your current blood pressure?
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Yes
No
Do you know your current cholesterol number?
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Yes
No
Do you know your current blood sugar or A1C?
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Yes
No
How would you rate your current health?
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Excellent
Good
Fair
Poor
How often do you exercise?
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Daily
Several Times Per Week
Occasionally
Rarely
How often do you eat fruits and vegetables?
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Daily
Several Times Per Week
Occasionally
Rarely
Select Three Habits You Commit To Improving
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Drink More Water
Walk More
Exercise Regularly
Improve Sleep
Reduce Sugary Drinks
Reduce Fried Foods
Eat More Vegetables
Reduce Sodium
Reduce Fast Food
Reduce Stress
Check Blood Pressure Regularly
Schedule Preventive Screenings
Meal Prep More Often
Improve Portion Control
Why are you taking the pledge?
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Improve My Health
Lower Blood Pressure
Prevent Diabetes
Improve Cholesterol
Lose Weight
Increase Energy
Improve Quality of Life
Support My Family
Be a Healthier Example
Other
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I Pledge To: (check all 3 to take the 3 vs 3 pledge)
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Make healthier daily choices
Take small steps toward better health
Encourage healthier habits within my community
Submit
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