Health Questionnaire

Name: _____________________________________________________________________Email: _____________________________________________________________________Sex M/F: ___________________________________________________________________Age: ______________________________________________________________________BMI (Approx): ____ 20-25 ____ 25-30 ____ 30-35 ____ 40+Health history - any problems: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________Goals - check all that apply so we can help you better:Learn more for right now     ___I want to have fun with the group    ___Learn to eat healthier     ___Become active enough     ___Lose weight by diet and exercise    ___Better health     ___Other __________________________Eating habits:Eat breakfast     ___ most days    ___ not usuallyEat healthy breakfast     ___ most days    ___ almost neverPack my own lunch     ___ most days    ___ no, I eat outCook dinner     ___ most days    ___ eat out mostlyEat out     ___ 1-2 times per week    ___ x per weekFavorite snacks     ___ fruit, yogurt veggies    ___ candy, chips, crackersMostly drink:     ___ water/plain tea or coffee      ___ creamy stuff or sodaAlcohol drinks    ___ 1-2 per week or none    ___ more than 5 per weekSmoke    ___ never    ___ x per weekFavorite foods when eating out:     ___ salads, soups, pasta    ___ fast food, fried foodExercise:    ___ 3-7 days    ___ don’t have timeIf you have questions with this form please contact:Top 3 goals to do right now:____ smoke free or less alcohol____ prepare healthier foods____ 5-7 hours exercise/week____ don’t skip breakfast____ choose better foods____ choose better beveragesRealistic goal weight:________Ideal goal for weight loss:_______NOTES: ______________________