Nutritional Health Risk Assessment
Full Name
Age
Gender
Male
Female
Other
Height (cm)
Weight (kg)
How many servings of fruits and vegetables do you consume daily?
How many sugary drinks do you consume per week?
How many times do you eat fast food per week?
Do you have any of the following? (Check all that apply)
Diabetes
Hypertension
High Cholesterol
None
Physical activity per week (minutes)
Additional Comments