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:

• Red meat (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Chicken (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Fish (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Chips (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Ice cream/Frozen yogurt (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 -- per week
• Yogurt (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Cheese (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week
• Cottage cheese (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 -- per week
• Restaurant meals (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 --8 -- 9 --10 -- 11 -- 12 -- per week

How many servings do you each DAY of:

• Milk (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- per day
• What kind of milk (circle number) -- skim --- 0 -- 1% milk --- 2% milk --- whole milk -- per day
• Fruits (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- per day
• Vegetables (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- per day
• Cans/glasses of soda (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- per day
• Sweets (cookie/candies) (circle number) -- 0 -- 1 -- 2 -- 3 -- 4 -- 5 -- 6 -- per day

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

Please list your family members (parents, siblings, children) on the back of the paper, and list any medical problems that they have. Please also list more distant relatives (aunts, uncles, grandparents) who have medical problems that we should know about (for example, cancer, heart problems).
Please turn this page over and answer the questions on the back after completing this question.

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):