Health Review

If you feel uncomfortable answering any question, please feel free to skip to the next question.
How many times per week do you exercise? What type of exercise do you do (walking, biking, treadmill, etc.)?




How many servings do you each WEEK of:

How many servings do you each DAY of:

What vitamins, supplements, minerals or herbal remedies do you take? How often? (use back of page if needed)



Please list your family members (parents, brothers and sisters) and list any medical problems that they have. Please also list more distant relatives who have significant medical problems.
Please turn the paper over for a few more questions.

  1. Do you wear a seatbelt in the car?
    Yes ________ No ________
  2. Do any of your teachers have tuberculosis, or an unexplained chronic cough?
    Yes ________ No ________
  3. Have you or your parents traveled out of the country in the past year?
    Yes ________ No ________
    If so, where? ________________________________________________
  4. Have you lived with or spent time with anyone who possibly or definitely had tuberculosis, or had a positive skin test for tuberculosis?
    Yes ________ No ________
  5. Did you, your parent, or anyone else living in your household come to the United States from another country?
    Yes ________ No ________
    If so, from which country? ____________________________________________
  6. Have you lived with or spent time with adults who:

Please check-off any problems you have had in the past MONTH that you would like to discsuss further (please feel free to write in more detail next to the problem or at the bottom of the page):