1. First Name Last Name Gender Birthdate Truck Number
MALE
teter FEMALE
Address 1 Address 2 State City Zip Code
--
Work Phone Home Phone E-Mail
Job Description Location Company Status
What is your percent Body Fat?...... 12.1
What is your current Weight?............................................................... Pounds
What is your current Height?............................................................... 6 Feet 1 inches
What is your current Waist Measure?..................................................... inches
What is your current Hip Measure?......................................................... inches
What is your current Neck Measure?...................................................... inches
What is your Heart Rate & Blood Pressure? What are your most recent
Cholesterol Numbers?
Blood Pressure……………. / Total Cholesterol………
Heart Rate…………………… Triglycerides……………
HDL………………………
What are your Blood Sugar Measures?
LDL………………………
Glucose……………………………….
HbA1c…………………………………

2. Do you Smoke? YES NO USED TO Mark the choice that is most like your plans
about smoking cigarettes:
If 'Yes', How Much? per day
I Do not Smoke
If you 'Used To' Smoke, When Did You Quit I do not plan to quit smoking within the next 6 months
ago
I am thinking about quitting smoking within the next 6 months
Do You Smoke or Use… I am making plans to quit smoking within the next 30 days
s Pipes s Cigars s Smokeless Tobacco I am currently trying to quit smoking
Do you work or live with anyone who regularly smokes around you? YES NO
Do you feel that you fully understand the health risks of tobacco use? YES NO
In general, how satisfied are you with the balance between your personal life and your professional life?
Completely Satisfied Mostly Satisfied Partly Satisfied Not Satisfied
How often do you brush your teeth? q Never or Rarely q Once per Day q 2 or More Times per Day
Do you floss daily? YES NO
Considering your age, How would you describe your overall health?
Excellent Very Good Good Fair Poor
When you lift a heavy object do you bend your knees and keep your back straight? YES NO
When in the sun, do you use sunscreen or wear adequate clothing? YES NO
In the past 12-months, how many times have you:
0 1-2 3-5 6 or more
Visited a Physician's Office or Clinic
Gone to an Emergency Room
Stayed Overnight in a Hospital
In the next 3-months, are you planning to make any changes to keep yourself healthy or improve your health?
I'm Already Want to start working
Yes No Not Needed
Doing This on this today
Increase Physical Activity Choose only 1
Lose Weight Choose only 1
Reduce Alcohol Use Choose only 1
Quit or Cut Down Smoking Choose only 1
Reduce Fat and/or Cholesterol Intake Choose only 1
Lower Blood Pressure Choose only 1
Lower Cholesterol Level Choose only 1
Cope Better With Stress Choose only 1

3. How many times per day do you eat a meal?
How often do you eat Hight Fat Foods?
How often do you Snack? Once Per Day Twice Per Day Several Times Per Day
What types of Snacks? Fruits, Veggies, Grains High Fat (Chips) High Sugar (Candy)
Drinks Number per Day
Would you be interested in completeing a 5-day
s Regular Soda nutrition log to get a better idea about your
nutritional needs?
s Diet Soda
YES NO
s Water
s Energy Drinks
Mark on the response which best describes your plans for eating more fruits and/or vegetables:
I do not plan to eat more fruits and/or vegetables within the next 6 months
I am thinking about eating more fruits and/or vegetables within the next 6 months
I am making plans to begin eating more fruits and/or vegetables within the next 30 days
I am currently trying to increase the amount of fruits and/or vegetables that I eat on most days
Mark on the response which best describes your plans for eating fewer High-Fat Foods:
I do not plan to eat fewer high-fat foods within the next 6 months
I am thinking about eating fewer high-fat foods within the next 6 months
I am making plans to begin eating fewer high-fat foods within the next 30 days
I am currently trying to decrease the amount of high-fat foods that I eat on most days
Mark on the response which best describes your plans for Drinking fewer High-Sugar Drinks:
I do not plan to drink fewer high-sugar drinks within the next 6 months
I am thinking about drinking fewer high-sugar drinks within the next 6 months
I am making plans to begin drinking fewer high-sugar drinks within the next 30 days
I am currently trying to decrease the amount of high-sugar drinks that I drink on most days
Mark on the response which best describes your plans for eating more Appropriate Portion Sizes:
I do not plan to eat more appropriate serving sizes within the next 6 months
I am thinking about eating more appropriate serving sizes within the next 6 months
I am making plans to begin eating more appropriate serving sizes within the next 30 days
I am currently trying to eat appropriate serving sizes on most days
Are you currently trying to lose weight? YES NO

4. How would you describe your physical activity level?
How many days per week do you get 30-minutes or more of continuous physical activity?
How many days per week do you do exercices specifically for your back and stomach?
How many days per week do you perform stretching exercises?
How often do you do strength building exercises like push ups, resistance bands, or weight lifting?
Have you increased the amout of exercise you do in a typical week?
Yes, In the last 6-months Yes, More than 6-months ago No
Mark the Boxes next to the TWO health benefits that are most important to you.
Check only TWO (2)
Build Endurance Heart Health s Reduce Blood Pressure
Control Diabetes Weight Loss s Reduce Injury Risk
Reduce Fatigue Build Muscle s Stress Management
In the next 6-months, would you participate in a program that would help improve your overall health?
Yes No Not Sure
How would you feel if someone were to see you exercising?
Proud Embarassed Wouldn't Care
Do you spend a lot of time thinking about ways to be / stay thin? Yes No
Have you had fun during the past two weeks? Yes No
Do you have any 'old injuries' that would make it hard for you to exercise? (check all that apply)
Neck s Pain s Weakness Decreased Range of Motion
Back Pain Weakness s Decreased Range of Motion
Shoulder Pain Weakness Decreased Range of Motion
Elbow Pain Weakness Decreased Range of Motion
Wrist s Pain Weakness s Decreased Range of Motion
Hip Pain Weakness Decreased Range of Motion
Knee Pain Weakness Decreased Range of Motion
Ankle Pain Weakness Decreased Range of Motion

5. Family History Mother Father Sister / Brother Grandparent
Heart Attack
Stroke
High Blood Pressure
High Cholesterol
Diabetes
Breast Cancer
Prostate Cancer
Colon or Rectal Cancer
Obesity
Depression
Alcoholism
Has a doctor ever told you that you Are you currently taking any of the following
have any of the following medications prescribed by your doctor?
conditions? Allergy Medication
Allergies Anti-Anxiety Medication
s Asthma
Asthma Medication (Inhaler)
Osteoarthritis
Asthma Medication (Pills)
Bone Loss / Osteoporosis
Aspirin (1/day for Heart)
s Breast Cancer
Blood Thinners (like Coumadin)
Prostate Cancer
Chronic Pain Medication
Colon or Rectal Cancer
Depression Medication
Lung Cancer
Insulin (Injected)
s Melanoma Skin Cancer
s Any Other Cancers Oral Diabetes Medication
Chronic Back Problems
s Heart Disease Medication
Depression High Blood Pressure Medication
Type I Diabetes High Cholesterol Medication
Type II Diabetes s High-Triglycerides Medication
Irritable Bowel Syndrome / Crohn's Disease Medication for Lung Disease (COPD/Emphysema/Chronic Bronchitis)
Stomach Ulcers Muscle Relaxants
Heart Disease / Angina / Heart Surgery Sleep Medication
High Blood Pressure
Are you currently taking any of these over the
High Cholesterol counter medications?
High Triglycerides Antihistamines
Lupus
Decongestants (for example: Sudafed)
Multiple Sclerosis Herbal Medications / Supplements
Rheumatoid Arthritis Sleep Medication
Kidney Disease Non-Prescription Pain Medication (Aspirin/Advil/Alieve)
Migrane Headaches
Epilepsy
Sleep Disorder
Stroke

6. Certain Medical and Self-Care Exams should be done on a regular schedule.
When was your last:
MEN
Physical Exam You should thouroughly
Dental Exam check your testicles
Vision Exam monthly for lump, pain,
or other changes.
Cholesterol Check
Flu Shot Do You Do This?
Tetanus Booster
YES NO
Hepatitis B Vaccine
MEN
Prostate Specific Antigen WOMEN
WOMEN You should thouroughly
Clinical Breast Exam check your breasts
Mamogram monthly for lump, pain,
or other changes.
Pap / Pelvic Exam
Do You Do This?
If You are Over 50 or have a Family History of Cancer: YES NO
When was your last:
MEN & WOMEN
Digital Rectal Exam You should thouroughly
Sigmoidoscopy check your skin monthly
Colon X-Ray for lump, pain, or other
changes.
Colonoscopy
Do You Do This?
WOMEN:
YES NO
Have you entered manopause? YES NO
How often do you feel fatgued or tired after your sleep?
Do you Snore? Yes No If yes, Your Snoring is:
Has anyone ever told you that you quit breathing during your sleep? Yes No
How do you feel that you are currently coping with life in general?
How often does your own anger or irritation upset your work or personal life?
Do you feel that you are able to speak openly about your feelings when you are angry or worried?
Yes No
Digitally signed by erik teter
erik teter
DN: cn=erik teter, o=linkamerica,
ou=linkwell,
email=eteter@gmail.com, c=US
Date: 2009.09.17 09:06:45 -05'00'