Gch Wellness Tracking Sheet

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GCH Wellness Tracking Sheet
Name:
Month:
Year:
= 1 pt
No Smoking
No
5 Fruits &
Wellness
Health
Date
Smoking
Veggies Exercise Education
Activity
Screening
5 Fruits & Veggies = 1 pt
(
must consume 5 servings to earn
1
point, no partial points)
2
3
Exercise 15 minutes = 1 pt
(Maximum 10 points per week)
4
5
Education: 1 approved
education opportunity = 10 pts
6
(maximum 100 pts per year)
7
8
Wellness Activity: 1 approved
wellness activity = 10 pts
9
(maximum 60 pts per year)
10
11
Health Screening: earn points
as listed below
12
13
Weight Loss: 1lb = 1 pt
14
(
maximum 10 pts)
15
16
17
Health Screen Points
18
Physical Exam = 20 pts
19
Lipid Profile = 10 pts
20
Fasting Glucose = 10 pts
21
Dental Exam = 20 pts
22
Vision Exam = 20 pts
23
Gynecological Exam = 20pts
24
Mammogram = 20 pts
25
Prostate Exam = 20 pts
26
Colorectal Exam = 20 pts
27
Clinical Skin Exam = 20 pts
28
29
30
31
Total
Beginning BMI: ______
Ending BMI: ______
Weight Management: Maintain BMI between 19-24.9 = 10 Points
Weight loss in lbs. (___ lb x 1 pt =)
Grand Total

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