We require the information below from participants to help inform and improve our services and to send you information about our programs and services.

For further information, contact the Prescription to Get Active (RxTGA) Program Director at 1 (866) 212-7552 Ext. 1 or send an email to

Personal Info







I identify as:




How much is your approximate household income? *not required


Activity Information

How much moderate to vigorous activity do you currently do each week (mintutes)?


How much moderate to vigorous activity have you been doing each week for the past 6 months (minutes)?


My level of motivation to become more physcially active in the next 6 months is:


Barriers to Activity

Are there any barriers that have stopped you from participating in physical activity previously? *not required



If yes, please select all that apply: *not required




Do you have a prescription already?