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Section 1 of 1
Form title
Health Questionnaire
Form description
Your information will be kept confidential and stored to be in compliance with GDRP.
Email address
*
Valid email address
Name
*
Question
Name
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
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Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
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Required
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Email
*
Question
Email
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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Phone number
*
Question
Phone number
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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Date of birth
*
Question
Date of birth
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
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Checkbox grid
Date
Time
Description
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Caption
Answer key
(0 points)
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Required
Required
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Gender
*
Question
Gender
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
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Multiple choice grid
Checkbox grid
Date
Time
Description
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Caption
Female yes
Male
Prefer not to say
Other…
Add option
or
add "Other"
…
Select at least
Select at most
Select exactly
Number
Custom error text
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(0 points)
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Required
Required
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What is your motivation for joining Seagrass?
*
Question
What is your motivation for joining Seagrass?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
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Required
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Do you feel there is anything getting in the way of you achieving your goals?
*
Question
Do you feel there is anything getting in the way of you achieving your goals?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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How would you rate your current fitness level
*
Question
How would you rate your current fitness level
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
1 (Low)
2
3
4
5
6
7
8
8
10 (High)
:
Rows
1.
:
1.
Other…
2.
Add row
or
add "Other"
Columns
1 (Low)
2
3
4
5
6
7
8
8
10 (High)
Other…
Add column
or
add "Other"
…
Answer key
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Required
Required
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How would you rate your motivation and readiness to start exercising?
*
Question
How would you rate your motivation and readiness to start exercising?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
:
Rows
1.
:
1.
Other…
2.
Add row
or
add "Other"
Columns
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
Other…
Add column
or
add "Other"
…
Answer key
(0 points)
Require a response in each row
Required
Required
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How would you rate your stress levels?
*
Question
How would you rate your stress levels?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
:
Rows
1.
:
1.
Other…
2.
Add row
or
add "Other"
Columns
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
Other…
Add column
or
add "Other"
…
Answer key
(0 points)
Require a response in each row
Required
Required
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How would you rate your emotional level?
*
Question
How would you rate your emotional level?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
:
Rows
1.
:
1.
Other…
2.
Add row
or
add "Other"
Columns
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
Other…
Add column
or
add "Other"
…
Answer key
(0 points)
Require a response in each row
Required
Required
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In Case of Emergency Contact Name:
*
Question
In Case of Emergency Contact Name:
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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Relationship to you
*
Question
Relationship to you
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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Are you currently under a doctor’s care?
*
Question
Are you currently under a doctor’s care?
*
Question Type
Short answer
Paragraph
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Checkbox grid
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Time
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Caption
Yes
No
Other…
Add option
or
add "Other"
…
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If yes please explain why
*
Question
If yes please explain why
*
Question Type
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Paragraph
Multiple choice
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Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
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Minimum character count
Number
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Required
Required
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Occupation and hours worked per week if applicable
*
Question
Occupation and hours worked per week if applicable
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Require a response in each row
Required
Required
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Lifestyle Information
*
Title
Lifestyle Information
*
Description (optional)
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Do you smoke?
*
Question
Do you smoke?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale