Healthy 4Life Assessment

Gender

Age

Height (in feet, inches)

Weight (in pounds)

Do you smoke?

How much water do you drink each day?

How many servings do you eat of these food groups every day?

Fruits (1 serving = 1/2 cup)

Dairy (1 serving = 1 cup of milk or yogurt or 1.5 ounces of cheese)

Vegetables (1 serving = 1 cup uncooked or 1/2 cup cooked)

Whole Grains (1 serving = 16 grams)

Sugars (1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

How much time do you spend sitting each day?

How many times per week do you spend at least 30 minutes doing the following types of activity?

Light Activity
(Minimal exertion, can talk easily or even sing)

Moderate Activity
(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity
(Labored breathing, difficult to talk, heavy sweating)

Please rate your current level of stress:

How many nights a week do you sleep for five hours or less?

Please rate your energy level:

Please rate the strength of your immune system:

What areas of your health would you most like to support? (pick up to 3)

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