Do you meet with your physician at least once a year for a check-up and any recommended medical tests?

In the past year, have you been seen by an emergency room doctor?

During the past six months, have your physical activity levels changed?

Compared to other people your age, how would you rate health overall?

The ability to make physical health improvements is within my control.

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

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

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

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

Please add any additional comments about your Physical wellness: