3 vs 3 Pledge

Welcome to the 3 vs 3 Pledge!

By participating, you are joining a community who are committing to three simple lifestyle changes that support better long-term health. Small changes can make a big difference. Thank you for completing this form. After you enter your information, we have 10 quick questions for you in order to get you started

Today's Date *

First Name *

Last Initial *

Mobile Phone *

Email *

Preferred Follow-Up Method (We will send you a quick check-in at 30, 60, & 90 days) *

Do you know your current blood pressure? *

Yes

No

Do you know your current cholesterol number? *

Yes

No

Do you know your current blood sugar or A1C number? *

Yes

No

How would you rate your current health? *

Excellent

Good

Fair

Poor

How often do you exercise? *

Daily

Several Times Per Week

Occasionally

Rarely

How often do you eat fruits and vegetables? *

Daily

Several Times Per Week

Occasionally

Rarely

I Pledge To: (check all 3 to take the 3 vs 3 pledge) *

Make healthier daily choices

Take small steps toward better health

Encourage healthier habits within my community

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