Health Assessment Survey

How would you rate your overall health? How would you rate your overall health? Excellent Good Fair Poor

How often do you exercise per week? How often do you exercise per week? 5 or more days 3–4 days 1–2 days Rarely

How many servings of fruits and vegetables do you eat daily? How many servings of fruits and vegetables do you eat daily? 5 or more days 3–4 days 1–2 days Rarely

How would you describe your stress level? How would you describe your stress level? Very low Low Moderate High

How many hours of sleep do you get per night? How many hours of sleep do you get per night? 8 or more 6–7 4–5 Less than 4

Do you have a primary care provider? Do you have a primary care provider? Yes No Looking for one Not sure

How often do you attend routine medical checkups? How often do you attend routine medical checkups? Annually Every few years Rarely Never

How would you rate your mental well-being? How would you rate your mental well-being? Excellent Good Fair Poor

Do you smoke or use tobacco products? Do you smoke or use tobacco products? No Former User Occasionally Yes

How much water do you drink daily? How much water do you drink daily? 8 or more cups 5–7 cups 3–4 cups Less than 3 cups