Health and Nutrition assessment form
The Health and Nutrition Assessment Form is a tool that can be used by health and nutrition professionals to assess the health and nutritional status of an individual or population.
2 minutes to complete
Eligibility
The Health and Nutrition assessment form is meant for all the families that want to be a part of the Head Start program.
Questions for Health and Nutrition assessment form
Questions
1.
How often do you eat breakfast?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
2.
How often do you eat fast food?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
3.
How often do you eat fruits and vegetables?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
4.
How often do you eat junk food?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
5.
How often do you eat out?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
6.
How much water do you drink each day?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
7.
How often do you exercise?
The answer should be a single choice:
- Always
- Often
- Sometimes
- Rarely
- Never
8.
What is your current weight?
The answer should be a number input.
9.
What are your current eating habits?
The answer should be a text input.
10.
What are your current fitness goals?
The answer should be a text input.
11.
What are your current health concerns?
The answer should be a text input.
12.
What medications are you currently taking?
The answer should be a text input.
13.
Have you ever been diagnosed with a chronic health condition?
The answer should be a single choice:
- Yes
- No
14.
Do you have any allergies?
The answer should be a single choice:
- Yes
- No
15.
Do you have any food preferences or restrictions?
The answer should be a single choice:
- Yes
- No
16.
Do you have any dietary supplements that you take regularly?
The answer should be a single choice:
- Yes
- No
Forms Similar to Health and Nutrition assessment form
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- Patient history form
- Physical activity assessment form
- Weight history form
Here are some FAQs and additional information
on Health and Nutrition assessment form
How do I complete the Health and Nutrition assessment form?
To complete the Health and Nutrition assessment form, you will need to provide information about your current health status, dietary habits, and physical activity level.
How often should I update my Health and Nutrition assessment form?
You should also update your form if you have any changes in your personal medical history.
How can I make sure that my Health and Nutrition assessment form is up to date?
You can make sure that your form is up to date by regularly reviewing it and updating it as needed.
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