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1 Assessment Quiz step 1 of 3   About you: First name:   Last name:   Age: 18 - 22 23 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - above (optional) Gender: Male Female   If you were given a Group Code, please enter it here: What is a group code? (optional) Are you Spanish/Hispanic/Latino?: (optional) No, not Spanish/Hispanic/Latino Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino What is your race?: (optional) White Black, African American, or Negro American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Other Pacific Islander Other ZIP Code: Email address:     Confirm email:     Select Password:       Confirm Password:     How did you hear about the website: Radio Television Whitecaps Another Website Friend/Family Healthcare Provider Newsletter Other     Move More 1. How many minutes of physical activity do you get in a usual day? (Hint: This question includes physical activities that increase your breathing and heart rate - even a little.) 0 1 - 15 16 - 29 30 - 45 46 - 59 60 or more Eat Better 2. How many servings of vegetables do you eat in a usual day? (Hint: A serving is not as much as you might think! 1/2 cup fresh, canned or frozen vegetables, 1 medium piece of vegetable, 3/4 cup of 100% fruit vegetable juice, or 1/2 cup cooked legumes.) 0 1 2 3 - 4 5 or more 1. How many servings of fruit do you eat in a usual day? (Hint: A serving is not as much as you might think! 1/2 cup fresh, canned or frozen fruit, 1 medium piece of fruit, 3/4 cup of 100% fruit juice or 1/4 cup dried fruit.) 0 1 2 - 3 4 or more     Stop Smoking 1. Have you smoked cigarettes, cigars, or pipes at least once in the last 30 days? Yes No   2. Have you used spit tobacco (also known as snuff, chew or dip) at least once in the past thirty days? Yes No   Secondhand Smoke 1. Is your home smoke free? Yes No   2. Is your car smoke-free? Yes No   3. Do you ever dine in restaurants that allow smoking? (Hint: Sitting in a non-smoking section does not completely protect you from secondhand smoke.) Yes No   Please note: We are committed to protecting your privacy. Please review our Privacy Policy to learn more about how we handle your information. Michigan.gov Home | Privacy Policy | Link Policy | Accessibility Policy | Security Policy | Michigan News Copyright © 2001-2005 State of Michigan