Living 365 Post Health Assessment
Name
*
First Name
Last Name
Email Address
How would you rate your overall health?
*
Please Select
1 Very poor
2 Poor
3 Fair
4 Good
5 Very good
Have you had a well visit in the last year?
*
Yes
No
How would you rate your ability to make healthy food choices to manage weight?
*
Please Select
1 Very Low
2 Low
3 Fair
4 High
5 Very High
True or False: Physical activity plays a role in managing health conditions?
*
True
False
How many days per week do you spend 30 minutes or more exercising?
*
Please Select
0
1-2
3-4
5-6
7
Do you have diabetes?
*
Yes
No
How would you rate your ability to manage your diabetes?
Please Select
1 Very Low
2 Low
3 Fair
4 High
5 Very High
How would you rate your ability to choose foods that can help manage your blood sugar levels?
Please Select
1 Very Low
2 Low
3 Fair
4 High
5 Very High
Do you check your blood sugar levels regularly?
Yes
No
Has you HBA1C been tested in the last 90 days?
Yes
No
If yes, what is your HBA1C?
Less than 7
7 - 9
Greater than 9
Have you had a retinal eye exam in the last year?
Yes
No
Have you had a kidney health evaluation in the last year?
Yes
No
Are you taking a Statin medication (medication to lower cholesterol)?
Yes
No
Do you have hypertension (high blood pressure)?
*
Yes
No
How would you rate your ability to manage your blood pressure?
Please Select
1 Very Low
2 Low
3 Fair
4 High
5 Very High
How would you rate your ability to choose foods that promote better blood pressure control?
Please Select
1 Very Low
2 Low
3 Fair
4 High
5 Very High
How often do you check your blood pressure?
Please Select
1 Never
2 Only during medical appointments
3 Monthly
4 Weekly
5 Daily
Was your most recent blood pressure reading less than 140/90?
Yes
No
Are you currently pregnant?
*
Yes
No
True or false: I can eat whatever I want because I'm eating for two during my pregnancy
True
False
Which foods should you avoid during pregnancy? (Select all that apply)
Deli meat
Nuts
Soft-cooked or runny eggs
Raw fish/sushi
Yogurt
Rare or undercooked meat
Beans
True or false: you should take prenatal vitamins throughout your entire pregnancy.
True
False
During your first two trimesters, did you have 1 prenatal visit per month?
Yes
No
During weeks 28 to 36, did you have 1 prenatal visit every 2 weeks?
Yes
No
N/A: Less than 28 weeks pregnant
During weeks 36 to 40, did you have 1 prenatal visit every week?
Yes
No
N/A: Less than 36 weeks pregnant
Were you screened for depression during your pregnancy?
Yes
No
Have you given birth in the last 12 months?
Yes
No
Did mom and baby have a post natal visit 2-3 days after birth?
Yes
No
Did mom and baby have a post natal visit 7-14 days after birth?
Yes
No
N/A: Less than 7-14 days post partum
Did mom and baby have a post natal visit 6 weeks after birth?
Yes
No
N/A: Less than 6 weeks post partum
Were you screened for depression during your pregnancy?
Yes
No
Were you screened for depression after your pregnancy?
Yes
No
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