Test Shop – New Hope Mission

HEALTH AGE QUESTIONNAIRE

Name of Person Completing this form: Additional notes0 / 180

Today's Date

Email Address *

Date of Birth

Your Age

Phone Number *

Prefix

First Name *

Middle Name

Last Name *

GenderMaleFemale

Height

Weight

Date of Consent

What is your current health status?ExcellentGoodFairPoor

PHYSICAL ACTIVITY: TIME SPENT DOING MODERATE ACTIVITIES DAILY

Walking Briskly

Cycling

Low Impact Aerobics

Gardening

PHYSICAL ACTIVITY: TIME SPENT DOING VIGOROUS ACTIVITIES DAILY

Jogging

Biking

Cardio Workout, etc.

DIETARY HABITS - SERVINGS/DAY:

3. Whole Grains (1 Serving = 1 slice of whole wheat bread, 1/2 cup of cooked cereal, 2/3 cup of whole grain ready-to-eat cereal)

4. Fruit (1 Serving Equals: 1 medium banana, orange or apple, 1 cup fresh fruit, 1/2 cup cooked fruit, 3/4 cup 100% Fruit Juice)

5. Daily Servings of Vegetables? (1 Serving Equals: 1 cup raw vegetables, 1/2 cup cooked, 2 cups fresh green salad, 3/4 cup vegetable juice)

6. Daily Servings of Meat? (1 Serving Equals: 3 ounces - Approx. size of palm of hand)

7. Daily Nuts & Seeds? (1 Serving Equals: 1 oz - nuts or seeds, 2 T nut butter)

8. Daily Water Intake?

9. Sodium Intake includes: chips, condiments, packaged soups, sprinkled salts, etc.NeverSparinglyDon't see the need to limitEat High Sodium Food and use salt freely

OTHER LIFESTYLE FACTORS:

10. Daily Alcoholic Drinks Consumed? (1 Serving Equals: 5 oz wine, 12 oz beer, 1.5 oz spirits)

11. Smoking Status: Smoking/Vaping/Marijuana, etc.Never SmokedEx-smokerCurrent Smoker

12. How often do you feel the following: tension, irritable, anxious, difficulty sleeping, stress at home, work or school?Never or SeldomSometimesOftenAlways or Continuously

13. Sleeping Hours/day

14. Social Support Status - check all that apply1. Married or in a relationship2. Frequently in contact with family and friends3. Regular participation in a faith-based group4. Regular participation in a social group

15. Current Emotional Status:1. Very Happy2. Happy most of the time3. Not very happy4. Very unhappy

OPTIONAL HEALTH TESTS:

Percent Body Fat

Waist Circumference

Blood Pressure

Total Cholesterol

HDL Cholesterol

Fasting Glucose

Non fasting Glucose

1 mile walk

Peak Aerobic Capacity

Grip Strength

Donate

Symptoms Questionnaire

Health Age Questionnaire

Creator's Choice Detox Kit

Coaching Skills Certification Training (11 Sessions)