Healthy Habits Adolescents Healthy Habits Adolescent Healthy Habits (Adolescent) Patient * DOB * (MM/DD/YYYY) Questions 1. I eat veggies (a serving is about the size of your fist) 0-1 servings 2-3 servings 3-4 servings more than 4 servers 2. I eat fruits (a serving is about the size of your fist) 0-1 servings 1-2 servings 3-4 servings more than 4 servings 3. I eat out More than 4 times a week 3-4 times a week 1-2 times a week 0-1 time a week 4. I am active Not very often Less than 30 minutes a day 30-60 minutes a day More than 60 minutes a day 5. I have sweet drinks (soda, sweet tea, 100% fruti juice, sports drinks, other fruit drinks) More than 3 cups a day 2 cups a day 1 cup a day Not very often 6. I watch television, play video games, spend (non-school related) time on the computer, tablet, or cell phone More than 2 hours a day 1-2 hours a day 30-60 minutes a day Not very often 7. Most nights, I sleep Less than 7 hours 7-8 hours 9-10 hours More than 10 hours 8. If you could work on one healthy habit, which would it be? Make half your plate veggies and fruits Limit screen time Be more active Drink more water and limit sugary drinks Get the right amount of sleep I am not ready to work on a healthy habit Submit If you are human, leave this field blank.
