Patient Lifestyle Risk Assessment Form
Patient Name
Age
Gender
Female
Male
Other
Prefer not to say
Tobacco/Alcohol Use
Tobacco Use
Never
Former
Current
Alcohol Use
Never
Occasionally
Regularly
Physical Activity
How many days per week do you exercise?
0
1-2
3-4
5-7
Type of Physical Activity
Dietary Habits
Diet Type
Balanced
Vegetarian
Vegan
High protein
Meals per Day
Servings of Fruits & Vegetables per Day
Sleep
Total Hours of Sleep (per night)
Do you have trouble falling or staying asleep?
Yes
No
Other Lifestyle Risks
Check any that apply:
High Stress
Sedentary Job
Overweight
Family History of Chronic Disease
Additional Comments