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RYC Survey

For any questions requiring video submission, tap on "Choose File" and you will be able to record your answer via your phone.

Name

Email

Phone Number

Links to socials:

What Is Your Name?

What Do You Do For A Living?

First Name

Last Name

Email

Sex

Male Female

1) What are your specific wellness goals?

2) To the best of your knowledge, what is your current height?

3) To the best of your knowledge, what is your current weight?

4) What is your goal weight

5) What is your target goal date?

6) Please select any food allergies.

None Milk Egg Peanut Shellfish Other

If "Other," please specify?

7) On average, how many meals do you consume per day?

8) How many meals are home cooked?

9) What is your cooking skill?

10) Which of the following breakfast items most interest you?

Baby Spinach Omelet Fluffy Scrambled Eggs Greek Yogurt Blueberry Banana French Toast Apple Cinnamon Oatmeal Bowl Creamy Avocado Smoothie Other

If "Other," please specify:

11) Which of the following lunch items most interest you?

Easy Apple Avocado Salad Caesar Salad BBQ Chicken Salad Carrot and Apple Soup Green Beans with Cherry Tomatoes Crab and Tuna Stack Other

If "Other," please specify:

12) Which of the following dinner items most interest you?

Breaded Turkey Breasts Grilled Chicken Teriyaki Grilled Salmon Maple Glazed Turkey Roast Apple Butter Baked Beans Hearty Veggie Stir Fry Other

If "Other," please specify:

13) Which of the following snack items most interest you?

Fresh Fruit Avocado Toast Homemade Granola Strawberry Banana Smoothie Strawberry and Oat Parfait Broiled Egg Other

If "Other," please specify:

14) Do you take any vitamins or supplements?

Yes No

If "Yes", list items:

15) Do you smoke?

Yes No

16) How many days can you workout?

17) What is your exercise level?

18) Please select your age range:

18-39 40-59 60+

19) Do you have any condition that would require a doctor's clearance?

Yes No

If "Yes", please specify:

20) Do you experience any of the following during physical activity?

Loss of balance Dizziness Loss of consciousness Chest pains Shortness of breath None

21) Do you have an existing or previous injury that may affect how you perform physical activities?

Upper Body Lower Body None

If "Yes", please specify:

22) Are you prescribed medication for blood pressure or a heart condition?

Yes No

If "Yes", please specify which condition:

23) Are you, or have you recently been pregnant?

Currently Pregnant Recently Pregnant Neither

24) Do you have access to a gym?

Yes No

List gym equipment that you have at home.

25) Check all that applies on your health and fitness goals.

Gain Muscle Lose Fat Maintain Current Weight Get Ripped Improve Overall Health

Leave a comment(Optional)

I agree to receiving marketing and promotional materials

Are you comfortable sharing your plans?

Yes No

For any questions requiring video submission, tap on "Choose File" and you will be able to record your answer via your phone.

Rep Your City (RYC) is communities coming together to show strengths and raising awareness of the 5 awarenesses; Anxiety, Fresh Water, Student Hunger, Small Business, Technology.

In your own words, what Is Rep Your City?

Why Represent One Of The 5 Awarenesses?

What Does RYC Mean To You?

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