Select the statement that best describes your plan for making changes in the following areas:

Please add any additional comments about your Physical wellness:

Do any of the following conditions limit your ability to participate as much as you would like in all activities?

How confident are you in your ability to enhance your physical health?

What is your current height (to the nearest inch, without shoes)?

What is your current weight (to the nearest pound, without shoes)?

Have you experienced a major setback including illness, accident or other event?

About how many days per week do you participate in gentle physical activity (chair exercise, yoga, tai chi, etc.) for at least 30 minutes?

About how many days per week do you participate in muscle strengthening activity (lifting weights, working with resistance bands, doing exercises that use your body weight, Pilates, etc.) for at least 30 minutes?

How many servings of fruits and vegetables do you eat during a typical day? (1 serving = 1 measuring cup)