Health Questionnaire

healthassessment

Name: _____________________________________________________________________
Email: _____________________________________________________________________
Sex M/F: ___________________________________________________________________
Age: ______________________________________________________________________
BMI (Approx): ____ 20-25 ____ 25-30 ____ 30-35 ____ 40+
Health history - any problems: ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Goals - check all that apply so we can help you better:
Learn more for right now     ___
I want to have fun with the group    ___
Learn to eat healthier     ___
Become active enough     ___
Lose weight by diet and exercise    ___
Better health     ___
Other __________________________

Eating habits:
Eat breakfast     ___ most days    ___ not usually
Eat healthy breakfast     ___ most days    ___ almost never
Pack my own lunch     ___ most days    ___ no, I eat out
Cook dinner     ___ most days    ___ eat out mostly
Eat out     ___ 1-2 times per week    ___ x per week
Favorite snacks     ___ fruit, yogurt veggies    ___ candy, chips, crackers
Mostly drink:     ___ water/plain tea or coffee      ___ creamy stuff or soda
Alcohol drinks    ___ 1-2 per week or none    ___ more than 5 per week
Smoke    ___ never    ___ x per week
Favorite foods when eating out:     ___ salads, soups, pasta    ___ fast food, fried food

Exercise:    ___ 3-7 days    ___ don’t have time

If you have questions with this form please contact:
Top 3 goals to do right now:
____ smoke free or less alcohol
____ prepare healthier foods
____ 5-7 hours exercise/week
____ don’t skip breakfast
____ choose better foods
____ choose better beverages
Realistic goal weight:
________

Ideal goal for weight loss:
_______

NOTES: ______________________

 

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