Health Check-In Template Question Title * 1. In general, how would you rate your overall health? Excellent Very good Good Fair Poor OK Question Title * 2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”. OK Question Title * 3. What is your current weight in pounds? OK Question Title * 4. Do you currently smoke cigarettes, or not? Yes, I do No, I do not OK Question Title * 5. About how many alcoholic drinks do you have each week? 0 1-4 5-8 9-12 13-16 More than 16 OK Question Title * 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. OK Question Title * 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 OK Question Title * 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 OK Question Title * 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 OK Question Title * 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 OK DONE