By completing the survey you help us to continue to offer these programs at no cost to you.

"*" indicates required fields

(MM/DD/YYYY)
MM slash DD slash YYYY
(MM/DD/YYYY)
MM slash DD slash YYYY
Name
How often do you exercise at home? * Required
How often are you active? * Required
How often are you sad or blue? * Required
How often do you gather with family/friends? * Required
How often do you fall? * Required
Over the past 3-months, about how many times have you participated in the Cognitive Physical Fitness class? * Required
Your level of participation makes a difference in how the program can benefit you personally.