CreateSurvey:

Gender Male Female Age under 18 18-29 30-39 40-49 50-59 60-69 70+ Height Weight (lbs.) Income less than $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - $150,000 $150,000+ Do you have a computer at home? Yes No Do you have high-speed internet access at home (DSL, cable modem, etc.)? Yes No Do you have wireless internet access (WiFi) at home? Yes No Do you regularly use any of the following health/fitness devices? Bathroom scale Pedometer (step counter) Heart rate monitor MP3 player while exercising How many diets or weight loss programs have you tried in the last 12 months? Count only those you tried for 3 days or longer. 0 1 2-4 5-10 10+ If you have tried any diets for longer than 3 days, which of the following have you tried: Jenny Craig Weight Watchers Other commercial program Gym-based program (personal trainer, etc.) Medical-based program (doctor, dietitian, nutritionist) Other Do you belong to a fitness center? Yes, and I go regularly Yes, but I rarely go No Which of the following types of exercise do you do regularly? Bike Exercise/fitness class Lift weights Run Swim Walk Other Have you ever kept track of your eating (e.g. calories, points, diary)? Yes No Which of the following have you purchased in the last 12 months to help reach your fitness or weight loss goals? Book/Magazine Commercial weight loss program membership Exercise equipment Fitness center membership Prepared meals (WeightWatchers, SlimFast, etc.) Professional services (trainer, nutritionist, etc.) Other If you are not currently on our mailing list, would you like us to add you? We send emails a few times a year with updates on Autom™. Enter your email address here: Would you like us to contact you to talk about your answers? If so, please let us know how you would like us to reach you. We'll contact you within the next 3 days to give you the opportunity to tell us more about your diet, weight loss, or fitness goals and challenges.