Healthy Lifestyle Assessment - Main Peds

  • Healthy Lifestyle Assessment

  •  - -
  •  - -

  • 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.*
  • My child drinks 1% or Skim (fat free) milk.*
  • My child eats breakfast every day.*
  • I am aware of the portion sizes of my child's meals and snacks.*
  • My child eats restaurant, fast food, or take-out less than 2 times a week.*
  • My child does drink juice.*
  • My child does drink sugar sweetened beverages (pop, lemonade, sports drinks).*

  • Activity Behaviors

  • My child has 2 hours or less of Screen Time every day (TV, computer, video games).*
  • My child has a TV free bedroom.*
  • My child does 1 hour or more of moderate Physical Activity every day.*

  • 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)*
  • Early heart attack (men under 40, women under 50)*
  • High cholesterol*
  • High blood pressure (Hypertension)*
  • Overweight*
  • Early Stroke (men under 40, women under 50)*

  • Please let us know more about what you think of your child's health:

  • Are you concerned with your child's weight?*
  • Do you think that your child is overweight?*
  • Do you think that your entire family is able to make lifestyle changes to improve their health?*

  • 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: