Hispanic Obesity Prevention and Education Program

Diet and Fitness Evaluation

Congratulations on taking the first step to a healthier life and feeling great!

Take the first step towards improving your health! Answer a few basic questions about your own eating and physical activity behaviors and you will receive FREE feedback on whether you should improve or maintain your current habits.

Please provide us with the following information:

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	First name:	*
	Last name:	*
	E-mail address:	*
	Confirm e-mail address:	*

	Password:	*
	Confirm password:	*

In which country were you born? *

In which country were your parents born? *

Language spoken at home? *

In what language would you prefer to take the evaluation? *

Are you Hispanic/ Latino? YesNo

What is your race?

How did you hear about this evaluation? *

Telephone:

To receive your Free DVD by mail, you need to complete the evaluation and view your results. Additional instructions to request the DVD will be provided to you when you view your results.

	Address:
	Address 2:
	City:
	State:	Florida
	Postal code (zip)	*



And now, let's get started!
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Diet and Fitness Evaluation

To receive your Free DVD by mail, you need to complete the evaluation and view your results. Additional instructions to request the DVD will be provided to you when you view your results.