Black Pledge SURVEY QUESTIONS

Today's Date * +

Your email address? *

Gender *

Female

Male

Other Other

Please rate your current health from the choices below *

Very Good

Good

Fair

Poor

Before responding please review the following link for healthy guidelines to help reduce CKD.

Please provide your status for this week. *

	Excellent	Very Good	Good	Fair	Poor
Maintaining a healthy diet	Excellent	Very Good	Good	Fair	Poor
Maintaining an active lifestyle	Excellent	Very Good	Good	Fair	Poor
Managing stress	Excellent	Very Good	Good	Fair	Poor
Monitoring your health	Excellent	Very Good	Good	Fair	Poor

Please share the amount of exercise you completed this week. (Enter any combination that applies below)

Number of steps

Number of miles

Number of hours

Other

How many hours of exercise did you complete this week?

On average how many hours of sleep did you get each night during the week?

(Optional) Comments you'd like to share regarding any of the 4 pledge objectives?