Health & Wellbeing Assessment Form
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5Health & Wellbeing Assessment Form
Date
Name (Last, First, MI)
Date of Birth
Priorities for Health and Wellness
Please rank from 1 to 8 in order of importance with 1 being the highest & 8 being the lowest.
Blood pressure management
Pre-diabetes / Diabetes management
Cholesterol reduction
Stress reduction
Healthy eating plan
Tobacco cessation
Increase physical activity
Weight management
Physical Activity
Please list how many days per week, minutes, and types of the following activities you are engaged in.
Days per week
Minutes per day
Type of activity
Aerobic/Cardiovascular
Balance
Flexibility/Stretching
Strength/Resistance
My Readiness to Change - Physical Activity
My readiness to make changes or improvements to reach or sustain regular physical activity:
□
I am already maintaining good physical activity levels consistently (6 mos.+).
□
I recently started working on this.
□
I am planning a change this month.
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I am planning a change to start in the next 6 months.
□
I have no present interest in making a change.
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Parent category: Medical