Healthy Lifestyle Assessment

Healthy Lifestyle Assessment
Patient's Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Your Email*
example@example.com
Please answer these questions regarding your child's health behaviors so that we may assist you and your family with maintaining a healthy lifestyle.

The following items have been shown to lead to children being overweight and therefore being at risk for long-term health problems. Your healthcare provider will discuss these items with you at today's visit.
Dietary Behaviors
My child eats 5 or more servings of Fruits and Vegetables most days.*

YesNo
My child drinks 1% or Skim (fat free) milk.*

YesNo
My child eats breakfast every day.*

YesNo
I am aware of the portion sizes of my child's meals and snacks.*

YesNo
My child eats restaurant, fast food, or take-out less than 2 times a week.*

YesNo
My child does drink juice.*

YesNo
My child does drink sugar sweetened beverages (pop, lemonade, sports drinks).*

YesNo
Activity Behaviors
My child has 2 hours or less of Screen Time every day (TV, computer, video games).*

YesNo
My child has a TV free bedroom.*

YesNo
My child does 1 hour or more of moderate Physical Activity every day.*

YesNo
Family Health History
Do any of the following Health Conditions occur in your child's family members (parents or grandparents)?
Diabetes, Type 2 (adult onset)*

NoYes
If "Yes", who?
Early heart attack (men under 40, women under 50)*

NoYes
If "Yes", who?
High cholesterol*

NoYes
If "Yes", who?
High blood pressure (Hypertension)*

NoYes
If "Yes", who?
Overweight*

NoYes
If "Yes", who?
Early Stroke (men under 40, women under 50)*

NoYes
If "Yes", who?
Please let us know more about what you think of your child's health:
Are you concerned with your child's weight?*

NoYes
Do you think that your child is overweight?*

NoYes
Do you think that your entire family is able to make lifestyle changes to improve their health?*

NoYes
What do you think is the greatest obstacle in your family to maintain a healthier lifestyle? For example: lack of healthy food; knowledge on food and nutrition; lack of outside play time; no safe outside place to play; unhelpful family members; genetics; child motivation.
Should be Empty:

Healthy Lifestyle Assessment

Dietary Behaviors

Activity Behaviors

Family Health History