Tobacco Usage
(Mark all that apply)

Diet/Eating Habits

What is your average intake per day of the following items?

Do you eat snacks between meals?   

Yes No    

If yes, what? 

Are you dieting now?    Yes No     

If yes, name dietary program:

 

What was your weight six months ago?    

What was your weight at age 21?  

Activity Level

Do you engage in a regular program of physical activity?  Yes No
 

If yes, what?  

How often do you exercise?

Never Once a week Twice a week 3 or more times a week

How much time do you spend exercising each time that you exercise?

30 minutes or less 1 hour 2 hours 3 or more hours

Do you have discomfort or shortness of breath with exercise?  Yes No
 

If yes, explain:  

Do you experience any pain with exercise? Yes No
If yes, explain:  

Is your occupation?  

Sedentary Active Heavy work

Fitness

How would you describe your state of well-being at this time?   

Average Good Very Good Poor Very Poor

 

Please type your email address so that we can contact you:

First Name:

Last Name:

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If you have any questions, please call the Wellness Testing Center at 782-5114.