Health Habits Form

MY HEALTH HABITS

Circle the foods your family eats on a regular basis

Food Choices

I cook with:

Other:

Fruit I like:

Other:

My Veggies are:

Other:

For Breakfast I eat:

Other:

My pastas are:

Other:

Type of bread/wrap I use:

Other:

Condiments I often use are:

Other:

I Sweeten With:

Other:

I like to drink:

Other:

The milk I use is:

Other:

Some meats I use are:

Other:

The Snacks I eat are:

Other:
Lifestyle & Habits

How Often I eat Fast Food:

How Often I Eat Out at Restaurants:

How often I eat out of Vending Machines or Gas Station Snacks:

My Exercise Habits:

My Daily Stress:

Work stress (1=low, 10=worst):
Home stress (1=low, 10=worst):

I would rate my unwinding techniques as:

My Quality of Life:

Overall quality of life (1–10):
In the morning I feel (1–10):
In the evening I feel (1–10):

Please list the following medications: