Weight loss, nutrition & Health management and Exercise

Lifestyle and Health Risk Questionnaire

Your Name:

Age:

Sex:

Height (inches):

Weight (lbs)

On average, how many days per week do you exercise or do physical activity?

On average, how many minutes of physical activity or exercise do you perform on each of those days?

At what intensity (how hard) do you usually exercise?

On average, how many minutes of physical activity or exercise do you perform on each of those days?

What types of physical activity do you do?

How often do you do muscle strengthening activities or exercises?

How many “screen-time” hours do you have each day: TV, video games, sitting at the computer (not counting work and school)?

How many total hours sitting do you have each day (including at work and school)?

On a scale of 1–10, where 1 is low and 10 is high, how ready, willing, and able are you to improve your activity habits and stick to it?

On average, how many days a week do you eat a healthy breakfast?

On average, how many 12-ounce servings of sweetened drinks do you have each day?

On average, how many servings of fruits and vegetables do you eat each day?

On average, how many meals per week do you eat with your family?

On average, how many servings of dairy do you have each day?

On average, how many drinks of alcohol do you have each day? HELP2 (1 drink = 12-ounce beer, 5-ounce wine, 1.5-ounce liquor)

How often do you eat while doing other things like watching TV?

Do you ever eat in secret?

On a scale of 1–10, where 1 is low and 10 is high, how ready, willing, and able are you to improve your nutrition habits and stick to it?

Physical Activity / Nutrition