Physical Activity Submission Log

Physical Activity Submission Log
First day of week reporting*

MonthDayYear
Last day of week reporting

MonthDayYear
Date
Full name*

First NameLast Name
Address

CityState

Zip Code
Email address*
Email
Did you attend any free fitness classes with Move More Eat Healthy?*

YesNo
Did you meet your the two and a half hours of physical activity a week for adults?*

YesNoPartially
Did you experience any problems or issues that kept you from being physically active?
What types of physical activity did you do?

WalkingRunningBikingSwimmingZumbaOther
How many total steps did you complete this week?
Attach file or document (i.e fitness log, screen shot of fitness app log)

Upload a File

Cancelof
What can Move More Eat Healthy do to help you reach your fitness goals?
Are there any other fitness classes you would like to see near you?
Have you pledged to Move More this Summer 2019 yet, and promised to get two and a half hours of physical activity a week for adults?

YesNo
Should be Empty: