Health & Wellbeing Assessment Form Page 3
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5Health & Wellness Assessment Form
Name:
DOB:
Nutrition (continued)
Water: How many eight ounce glasses of water do you drink on average per day?
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None
3 - 5 glasses
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1 - 2 glasses
6 - 8 glasses
Soft drinks: How many eight ounce glasses of non-diet soft drinks do you drink on average per day?
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2 glasses
6 - 8 glasses
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3 - 5 glasses
Seldom or never
My Readiness to Change - Nutrition
My readiness to make changes or improvements to consume healthy food and drinks:
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I am already consuming healthy food and drinks consistently (6 mos.+).
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I recently started working on this.
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I am planning a change this month.
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I am planning a change to start in the next 6 months.
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I have no present interest in making a change.
General Health
Complete the following statement. In general, my overall health is...
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Poor
Very good
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Fair
Excellent
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Good
Physician relationship: Do you have a primary care doctor who you trust and see regularly?
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Yes
No
Somewhat
Physical exam: When was your last physical examination?
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Five or more years ago
One to two years ago
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Three to four years ago
Within the last year
Please list the following:
My Numbers
Don't Know
Blood pressure
Total cholesterol
HDL cholesterol (good cholesterol)
LDL cholesterol (bad cholesterol)
Triglyceride level
Fasting glucose or Hemoglobin A1c
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Parent category: Medical