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Health Check-In Template

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.
1.In general, how would you rate your overall health?
2.What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.
3.What is your current weight in pounds?
4.Do you currently smoke cigarettes, or not?
5.About how many alcoholic drinks do you have each week?
6.How many hours do you sleep each night?
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7.About how many times in the average week do you engage in 30 minutes of light activity (i.e. leisurely walking, gardening, cleaning around the house)?
8.About how many times in the average week do you engage in 30 minutes of moderate activity (i.e. brisk walking, light bicycling)?
9.About how many times in the average week do you engage in 30 minutes of strenuous activity (i.e. running or jogging)?
10.How often do you use sunscreen while out in the sun?
Current Progress,
0 of 10 answered