Health & Wellbeing Assessment Form Page 5
Download a blank fillable Health & Wellbeing Assessment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health & Wellbeing Assessment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Health & Wellness Assessment Form
Name:
DOB:
Sleep and Stress (continued)
My Readiness to Change - Stress and Sleep
My readiness to make changes or improvements to reach and sustain optimal stress and sleep levels:
□
I am already maintaining good levels consistently (6 mos.+).
□
I recently started working on this.
□
I am planning a change this month.
□
I am planning a change to start in the next 6 months.
□
I have no present interest in making a change.
Tobacco
Tobacco status: Mark the appropriate response.
□
□
Use chewing tobacco regularly
Smoke pipe or cigar only
□
□
Currently smoke 10 or more
Quit smoking less than two years ago
cigarettes daily
□
Quit smoking two or more years ago
□
Currently smoke < 10 cigarettes
□
Have never smoked (or used tobacco)
daily
My Readiness to Change - Tobacco
My readiness to make changes or improvements in managing my tobacco use:
□
I am already maintaining tobacco cessation consistently (6 mos.+).
□
I recently started working on this.
□
I am planning a change this month.
□
I am planning a change to start in the next 6 months.
□
I have no present interest in making a change.
Thank you for completing this assessment tool.
Please check in 15 minutes prior to your appointment and bring the completed assessment with you.
5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical