Health Check-In Template

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* 1. In general, how would you rate your overall health?

Excellent

Very good

Good

Fair

Poor

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* 2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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* 3. What is your current weight in pounds?

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* 4. Do you currently smoke cigarettes, or not?

Yes, I do

No, I do not

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* 5. About how many alcoholic drinks do you have each week?

0

1-4

5-8

9-12

13-16

More than 16

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* 6. How many hours do you sleep each night?

1

12

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. About how many times in the average week do you engage in 30 minutes of light activity (i.e. leisurely walking, gardening, cleaning around the house)?

0

1

2

3

4

5 or more

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* 8. About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?

0

1

2

3

4

5 or more

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* 9. About how many times in the average week do you engage in 30 minutes of strenuous activity (i.e. running or jogging)?

0

1

2

3

4

5 or more

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* 10. How often do you use sunscreen while out in the sun?

Always

Often

Sometimes

Rarely

Never

Not applicable - I rarely go out in the sun