Health Survey

Health Questionaire

First Name *
Last Name *
Age *
Height *
Weight *
Address *
ZIP Code *
Telephone Number
Family E-mail Address
Gross Income (Approximate)

This survey below will help provide a baseline measurement of the residents of Southeastern Kentucky, Whitley County and surrounding areas.
Please take a moment to complete the following information.

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June 2019
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LEARN MORE

Find out about how Eating Healthy and Excercise can lead to a healthier lifestyle and change your life. Explore our site, the resources in the HEALTH Y LIVING LIBRARY in the menu above may be a good place to start.

PARTICIPATE

We are in the process of finalizing the project, and applications for inclusion in the Pilot Phase will be available soon. If you are interested, or know someone who is, then please check back in the next few days to download an application. Feel free to contact us if you have any questions.

GET ASSISTANCE

Our participants rely on us for reliable answers to your questions. E-mail us at info@project3E.org. We'll respond as quickly as possible — no more than 24 hours through the work week!

CONTACT US

To contact Project3E.org. Send mail to 1708 Forest Drive, Suite 104, Corbin, KY 40701. Phone: (606) 258-2788 Fax: (859) 258-7398 E-mail: info@project3E.org.