DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health Bureau of Community Health Promotion F-01220 (03/2019) Chronic Disease Prevention and Cancer Control Section HEALTHY LIFESTYLE ASSESSMENT SECTION 1 CLIENT AND PROVIDER INFORMATION – 1. Provider Agency Name 2. Print Performing Provider Name 3. Date of Integrated Office Visit 4. Client Name (Last, First MI) 5. Date of Birth 6. Client ID Number SECTION 2 – How many cups of fruits and vegetables do you eat in an average day? cups Do you eat fish at least two times a week? Yes No Thinking about all of the servings of grain products you eat in a typical day, how many are whole grains? Less than half About half More than half Do you drink less than 36 ounces (450 calories) of sugar-sweetened beverages weekly? Yes No Are you currently watching or reducing your sodium or salt intake? Yes No In the past 7 days, how often did you have a drink containing alcohol? Number of days: None How many alcoholic drinks, on average, do you consume during a day you drink? Number of drinks: None How many minutes of physical activity (exercise) do you get in a week? Number of Minutes: None Do you smoke? Includes cigarettes, pipes, or cigars (smoked tobacco in any form) Current smoker Quit 1-12 months ago Quit more than 12 months ago Never smoked Over the past 2 weeks, how often have you been bothered by any of the following? Little interest or pleasure in doing things: 0 Not at all 1 Several days 2 More than half 3 Nearly every day – – – – Feeling down, depressed, or hopeless: 0 Not at all 1 Several days 2 More than half 3 Nearly every day – – – –
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-01220 (03/2019) STATE OF WISCONSIN Bureau of Community Health Promotion Chronic Disease Prevention and Cancer Control Section SECTION 1 – CLIENT AND PROVIDER INFORMATION 1. Provider Agency Name 2. Print Performing Provider Name 3. Date of Integrated Office Visit 4. Client Name (Last, First MI) 5. Date of Birth 6. Client ID Number SECTION 2 – HEALTHY LIFESTYLE ASSESSMENT How many cups of fruits and vegetables do you eat in an average day? cups Do you eat fish at least two times a week? Yes No Thinking about all of the servings of grain products you eat in a typical day, how many are whole grains? Less than half About half More than half Do you drink less than 36 ounces (450 calories) of sugar-sweetened beverages weekly? Yes No Are you currently watching or reducing your sodium or salt intake? Yes No In the past 7 days, how often did you have a drink containing alcohol? Number of days: None How many alcoholic drinks, on average, do you consume during a day you drink? Number of drinks: None How many minutes of physical activity (exercise) do you get in a week? Number of Minutes: None Do you smoke? Includes cigarettes, pipes, or cigars (smoked tobacco in any form) Current smoker Quit 1-12 months ago Quit more than 12 months ago Never smoked Over the past 2 weeks, how often have you been bothered by any of the following? Little interest or pleasure in doing things: 0 – Not at all 1 – Several days 2 – More than half 3 – Nearly every day Feeling down, depressed, or hopeless: 0 – Not at all 1 – Several days 2 – More than half 3 – Nearly every day