Health Age Plus

Lifestyle Assessment and Health Screening

Biographical Information
1. Name _____________________________ 2. Age ____ 3. Gender 4. Height 5. Weight _____lb 6. How wo ld !o rate !o r "re#ent health$ (1) (2) (3) (4) %&'ellent Good (air )oor (1) male ___ft. (2) female ____in.

11. ruits and vegeta!les. How man! #er+ing# of fr it# and +egetable# do !o eat dail!$ "ne serving = 1 fresh fruit (orange, banana), 1C raw fruit/vegetable, C cooked, 6 o !uice" (1) .12 #er+ing# "er da! (2) 314 #er+ing# "er da! (3) 5158 #er+ing# "er da! 12. #uts. How man! #er+ing# of n t# do !o eat ea'h wee,$ "ne serving $ 1 o nuts, 2# nut butter (1) .12 #er+ing# "er wee, (2) 314 #er+ing# "er wee, (3) 5 or more #er+ing# "er wee, 13. Happiness. All in all- how ha""! are !o $ (1) not too ha""!- #ad mo#t of the time (2) "rett! ha""! (3) +er! ha""! and #ati#fied with life 13. Sleep. How often do !o get at lea#t5 *12 ho r# "er da!$ (1) #eldom- le## than 3 da!# "er wee, (2) o''a#ionall!- 314 da!# "er wee, (3) mo#t of the time- 51* da!# "er wee, 14. Social Support. N mber of #o'ial fa'tor# !o meet. $" %arried or have a significant other &" %ake a fre'uent contact with fa(ily and friends C" )egularly (eet in a faith grou* or social club (1) 3 meet all three of the#e #o'ial fa'tor# (2) 3 meet two of the#e #o'ial fa'tor# (3) 3 meet le## than two of the#e #o'ial fa'tor# %linical Assessment Wai#t Girth in0'm _______ (at 9______ :) _____0_____ 7otal 4hole#terol ________ H;<______<;<_______

Lifestyle Indicators
*. Physical Activity. How often do !o "arti'i"ate in moderate "h!#i'al a'ti+itie# (wal,- bi,e- #wim- mow lawn- golf) for at lea#t 3. min te# "er da!- or +igoro # a'ti+it! for at lea#t 2. min te# "er da!$ (1) no reg lar "h!#i'al a'ti+it! or /3 time#0wee, (2) 314 da!# "er wee, (3) 5 or more da!# "er wee, 2. Smoking. 3ndi'ate !o r "re#ent #tat #. (1) Ne+er #mo,ed (2) %&1#mo,er (3) 4 rrentl! #mo,e 5. Meat Intake. How often do !o eat meat (beef"or,- lamb- "o ltr!)$ (1) ne+er or le## than on'e "er month (2) #eldom- 1-3 time# "er month (3) e+er! wee, 1.. Whole grains. How often do !o eat whole1wheat bread and 'ereal# (oatmeal- brown ri'e- #hredded wheat)$ One serving 6 1 slice bread, 1/2 cooked cereal, 2/3C dry cereal (1) #eldom- .11 #er+ing# "er da! (2) 2 #er+ing# "er da! (3) 7hree or more #er+ing# "er da!

:lood = gar_______ >e#ting " l#e rate ________ Health Interests

3?m intere#ted in ,nowing more abo t@ (1) N trition (*) =tre## management (2) )h!#i'al (itne## (2) Heart health (3) Weight 'ontrol (5) ="irit al Health (4) =mo,ing 4e##ation (1.) Wellne## 'la## (5) :lood "re## re 'ontrol (11) 4hole#terol red 'tion (6) =elf1#t d! on health! li+ing &'( #otify me of health improvement opportunities) *o !e notified+ fill in phone+ email+ and address on the reverse side.