Health & Wellbeing Assessment Form Page 2
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5Health & Wellness Assessment Form
Name:
DOB:
Nutrition
Breakfast: How often do you eat breakfast?
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Eat breakfast every day
Eat breakfast two to three times per week
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Eat breakfast most mornings
Seldom or never eat breakfast
Snacks: How often do you eat "junk" snack foods between meals?
“Junk” snack food examples: chips, cookies, candy, ice cream
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Three or more times per day
Few times per week
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Once or twice per day
Seldom or never eat "junk" snack foods
Fat intake: Indicate the kinds of food you usually eat.
High fat examples: hamburgers, hot dogs, bologna, steaks, sour cream, cheese, whole milk, eggs,
butter, cake, pastry, ice cream, chocolate, fried foods, and many fast foods
Low fat examples: lean meats, skinless poultry, fish, skim milk, low fat dairy products, fruit
desserts, vegetables, pasta, legumes (peas and beans)
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Nearly always eat the high fat foods
Eat mostly low fat foods, some high fat
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Eat mostly the high fat food, some low fat
Eat only low fat foods
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Eat both about the same
Breads and grains: Indicate the kinds of breads and grains you usually eat.
Refined grain examples: white bread, rolls, regular pancakes and waffles, white rice, typical
breakfast cereals, typical baked goods
Whole grain examples: whole grain breads, brown rice, oatmeal, whole grain or high fiber cereals
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Nearly always eat refined grain products
Eat primarily whole grain products
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Eat mostly refined grain products
Eat only whole grain products
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Eat both about the same
I have gluten intolerance or allergies to
certain grains
Fruits and vegetables: How many servings of fruits and vegetables do you eat daily?
A serving is: 1 cup fresh, 1/2 cup cooked, 1 medium size fruit, or 3/4 cup juice
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One or less
Three daily
Five or more
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Two daily
Four daily
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Parent category: Medical