Health Needs Assessment
Answers marked with a * are required.
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1.
How old are you (in years)?
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2.
Do you consider your health to be:
Excellent
Good
Fair
Poor
3.
When was your last physical examination?
Within the last year
1-2 years ago
2-5 years ago
More than 5 years ago
4.
How would you describe your weight?
Very underweight
Slightly underweight
About the right weight
Slightly overweight
Very overweight
5.
Are you trying to:
Lose weight
Gain weight
Stay the same weight
I am not currently trying to do anything about my weight, but would like to
My weight does not concern me