Screening Survey

Thank you for your interest in participating in this research study. Please complete the brief screening survey to determine your eligibility for the study. This survey will take approximately 5-10 minutes of your time. Once completed, a research assistant will review your responses, contact you via phone, and provide you with additional information.
1. Last name
 
2. First name
 
3. Address
 
4. City
 
5. State
6. Zip Code
 
7. Phone Number
 
8. E-mail
 
9. How do you describe yourself? (check one)
Female  
Male  
Transgender  
Do not identify as female, male, or transgender  
10. What is your current age?
11. Are you Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin  
Yes, Mexican, Mexican American, or Chicano  
Yes, Puerto Rican  
Yes, Cuban  
Yes, another Hispanic, Latino, or Spanish origin  
Unavailable/Unknown  
12. Which category best describes your race?
American Indian/Alaska Native  
Asian  
Black or African American  
Native Hawaiian/Other Pacific Islander  
White  
Some other race  
Unavailable/Unknown  
13. Using your own terms, how would you describe your ethnic/racial identity?
 
14. What is your current height
15. What is your current weight (in pounds)? 
16. How would you describe your current activity level?
Sedentary (little or no exercise)  
Lightly active (light exercise/sports 1-3 days/week)  
Moderately active (moderate exercise/sports 3-5 days/week)  
Very active (hard exercise/sports 6-7 days a week)  
17. In what languages do you speak? (Please select all that apply)
English  
Spanish   
Navajo  
Other Native North American Languages  
Vietnamese  
Chinese  
German  
French  
Tagalog  
Korean  
Persian  
Japanese  
Russian  
Italian  
Arabic  
Other  
 If you selected other, please specify.
18. Do you have reliable access to the internet via a computer or Smartphone? 
Yes  
No  
19. Are you planning to move more than 90 miles from the Albuquerque area? 
Yes  
No  
20. Are you currently pregnant or planning to become pregnant? 
Yes  
No  
21. Are you currently in treatment for an eating disorder? 
Yes  
No  
22. Do you have type I diabetes, cancer, or have had a recent cardiac event (e.g., heart attack, angioplasty, etc.)
Yes  
No  
 If yes, please explain.
23. Are you currently taking any prescription medications for a chronic health condition? 
Yes  
No  
 If yes, please explain.
24. Are you physically able to walk for 10 consecutive minutes? 
Yes  
No  
25. Has a doctor or health care professional ever advised you that engaging in physical activity may not be safe? 
Yes  
No  
26. 

Are you willing to be randomized to a condition? 

Yes  
No  
PAR-Q
Please read the 7 questions below and answer each one honestly: check yes or no.
27. Has your doctor ever said that you have a heart condition and you should only perform physical activity recommended by a doctor? 
Yes  
No  
28. Do you feel pain in your chest when you perform physical activity? 
Yes  
No  
29. In the past month, have you had chest pain when you were not performing any physical activity? 
Yes  
No  
30. Do you lose your balance because of dizziness or do you ever lose consciousness? 
Yes  
No  
31. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 
Yes  
No  
32. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? 
Yes  
No   
33. Do you know of any other reasons why you should not engage in physical activity? 
Yes  
No  
 If yes, please explain.