Complete the Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Birthdate *How are you affiliated with the trucking industry? *Truck DriverSpouseOtherWhat choice best fits your job description? *OTR Driver - away 4+ nights/weekRegional Driver - away 4+ nights/weekRegional DriverLocal DriverPlease upload a copy of your CDL * Drag & Drop Files, Choose Files to Upload How did you hear about this program? *Employer (employer will NOT be notified of participation)What is your current weight? *What is your BMI? *Have you been diagnosed with any of the following? *DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseObesityOtherNone of the aboveIn the past year, have you had a fasting glucose or A1c test? *YesNoWhat was the result?If you know your blood pressure, please consider sharing here:On a scale of 1 to 5, how would you rank your overall health when it comes to energy level? Selected Value: 1 1 - very low energy, 5 - very high energy levelOn a scale of 1 to 5, how would you rank your overall health when it comes to movement/activity? Selected Value: 1 1 - completely sedentary, 3 - activity a few times each week, 5 - active for an hour each dayOn a scale of 1 to 5, how would you rank your overall health when it comes to sleep? Selected Value: 1 1 - consistently poor sleep, 5 - sleep is consistently greatOn a scale of 1 to 5, how would you rank your overall health when it comes to emotional health? Selected Value: 1 1 - very poor, 5 - greatHow many bottles of water (16.9 oz) do you currently drink on a daily basis? Selected Value: 1 1 - one bottle of water, 5 - five or more bottles of waterHow many servings of fruit and vegetables do you eat on a daily basis? Selected Value: 0 What are your biggest healthy living challenges while out on the road? *What are your current health goals? *What are you hoping to learn or gain from the Healthy Habits Program? *Which of the following devices do you currently have? *ScaleBlood pressure cuffGlucose monitorA1c home testFitness Tracker (example: Fitbit, Samsung Watch, Apple Watch)Body tape measureResistance bandsOther exercise equipmentSt. Christopher Fund is the creator and facilitator of the Healthy Habits and Diabetes Prevention courses. SCF employees are not doctors, do not diagnose or treat medical conditions, and will not provide information outside of their scope of practice. *By checking this box, you agree that you understand this information.Submit
