TEAM PRE-REGISTRATION FORM - COMMUNITY TEAM Enter Your Team Name: Your Business or Organization Name (optional): Address: Team Captain Information: First Name:Last Name: Street Address: Phone: Email Address (username): Create your login password: Type your password again: Optional Individual Wellness Assessment Questions: * A second assessment will be given at the end of the program to track the progress of the group as a whole. Please consider taking the time to answer the following questions. Thank you. 1. How many hours of sleep do you typically get daily? Less than 5 hours 5 - 6 hours 6 - 7 hours 8 or more 2. How much energy do you have during a typical day? High level of energy Adequate level Low level of energy Usually tired 3. How many servings of fruits and vegetables do you eat in a typical day? 1 or less 2 to 3 3 to 4 5 or more 4. How often do you feel stress during a typical day? Never Sometimes Often Continual stress 5. Do you typically eat breakfast each day? Never Sometimes Often Usually or Always 6. How many days of the week do you typically exercise? 0 to 1 days a week 1 to 2 days a week 3 to 5 days a week 6 to 7 days a week 7. How many minutes of exercise do you typically get on the day you exercise? 0 to 14 minutes 15 to 30 minutes 31 to 45 minutes 46 minutes or greater 8. How many times each week do you typically consume/eat fast food? 0 to 1 times a week 1 to 2 times a week 3 to 5 times a week 6 to 7 times a week 9. How much water do you typically drink each day? 0 to 16 ounces (2 glasses daily) 16 to 32 ounces (2 to 4 glasses daily) 32 to 48 ounces (4 to 6 glasses daily) 48 to 60 ounces (6 to 8 glasses daily) 64 ounces or more daily (8 plus glasses) 10. The suggessted optimal normal adult blood pressure is in the 120/80 range for most individuals. The Systolic number (or top number is 120). What is your systolic number typically? 100 to 120 mm Hg 121 to 140 mm Hg 141 to 160 mm Hg 160 mm Hg and above Unknown 11. The suggessted optimal normal blood pressure is in the 120/80 range for most individuals. The Diastolic (or bottom number) is 80. What is your diastolic number typically? 60 to 80 mm Hg 81 to 90 mm Hg 91 to 100 mm Hg 100 mm Hg and above Unknown