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-------Physical Activity-------

How many days a week do you exercise? [select name="Q1" value="|Never|Rarely Ever|1-2 Days Per Week|3-4 Days per week|5 or More Days"]

How many minutes do you exercise per day? [select name="Q2" value="|Not Applicable|Less than 30|30-60 Minutes|60-90 Minutes|More than 90 Minutes"]

How Intense is your typical exercise? [select name="Q3" value="|Not Applicable|Light (like stretching or slow walking)|Moderate (like brisk walking)|Heavy (like jogging or swimming)|Very heavy (like fast running or stair climbing)"]


-------Tobacco Use-------

Do you Smoke? [select name="Q4" value="|No|Yes"]

Do you Vape? [select name="Q5" value="|No|Yes"]

Do you use smokeless Tobacco? [select name="Q6" value="|No|Yes"]

Are you interested in quitting? [select name="Q6a" value="|No|Yes"]


-------Alcohol Use-------

Have you used alcohol in the past 7 days? [select name="Q7" value="|No|Yes"]

On days when you drank alcohol, how often did you have 4 or more drinks? [select name="Q8" value="|Not Applicable|Never|Once during the 7 days|2-3 times during the 7 days|More than 3 times during the 7 days"]

Do you ever drink and drive or ride with someone who is drinking and driving? [select name="Q8a" value="|No|Yes"]


-------Nutrition-------

How many servings of fruits and vegetables do you eat per day? [select name="Q9" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(1 serving = 1 cup of fresh vegetables, ½ cup of cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball.)"]

How many servings of high fiber or whole grain food do you eat per day? [select name="Q10" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole-wheat pasta.)"]

How many servings of fried or high-fat foods do you eat per day? [select name="Q11" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(Examples: include fried chicken, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese or mayonnaise.)"]

How many sugar-sweetened drinks do you have per day? [select name="Q12" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(Examples: Pop, Kool-aid, sweet tea, coffee with sugar and cream.)"]


-------Depression-------

In the past 2 weeks, how often have you felt down, depressed or hopeless? [select name="Q13" value="|Never|All of the time|Some of the time|Most of the time"]

In the past 2 weeks, how often have you felt little interest or pleasure in doing things? [select name="Q14" value="|Never|All of the time|Some of the time|Most of the time"]

Have your feelings caused you distress or interfered with your ability to get along socially with family or friends? [select name="Q15" value="|No|Yes"]


-------Anxiety-------

In the past 2 weeks, how often have you felt nervous, anxious or on edge? [select name="Q16" value="|Never|All of the time|Some of the time|Most of the time"]

Are you able to control your worrying? [select name="Q17" value="|Never|All of the time|Some of the time|Most of the time"]


-------High Stress-------

How often is stress a problem for you in handling such things as your health, your family or social relationships and your finances? [select name="Q18" value="|Never|All of the time|Some of the time|Most of the time"]


-------Social and Emotional Support-------

How often do you get the social and emotional support you need: [select name="Q19" value="|Always|Usually|Sometimes|Rarely|Never"]


-------Pain-------

In the past 7 days, how much pain have you felt? [select name="Q20" value="|None|Some|A Lot"]

What is your current pain level? [select name="P1" value="|None|1|2|3|4|5|6|7|8|9|10"]


-------General Health-------

In general, would you say your health is? [select name="Q21" value="|Excellent|Very Good|Good|Fair|Poor"]

How would you describe the condition of your mouth and teeth, including false teeth and dentures? [select name="Q22" value="|Excellent|Very Good|Good|Fair|Poor"]


-------General Health-------

In the past 7 days have you needed help with daily living activities? Examples include: eating, getting dressed, bathing, walking, housekeeping, shopping, food preparation or taking your medications. [select name="Q23" value="|No|Yes"]

How many hours of sleep do you get a night? [select name="Q24" value="|less than 4|4-6|6-8|more than 8"]

Do you snore or has anyone told you that you snore? [select name="Q25" value="|No|Yes"]

Do you feel sleepy during the daytime? [select name="Q26" value="|Always|Usually|Sometimes|Rarely|Never"]


-------General Health-------

What is your height without shoes?

Body Mass Index (BMI)
[select name="Height_ft" value="|1|2|3|4|5|6|7"]’ [select name="Height_in" value="|1|2|3|4|5|6|7|8|9|10|11"]”
[calc value="Height=((Height_ft)*(12))+(Height_in)"]
[text name="Weight"] <-- Weight in pounds
BMI Calculations
Class --> [calc memo="class" value="score=(Weight)*(703)/((Height)*(Height));score>59.9999?'Super-super obesity or class V obesity':score>49.9999?'Super-obesity or class IV obesity':score>39.9999?'Extreme obesity or class III obesity':score>34.9999?'Obesity class II':score>29.9999?'Obesity class I':score>24.9999?'Overweight':score>18.4999?'Normal':score>16.4999?'Underweight':'Severely underweight'"]
BMI --> [calc memo="bmi" value="score1=score.toFixed(1)"]

[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
Obesity Evidence at [link url="http://www.aafp.org/afp/2010/1015/p974.html" memo="#1"] Delaet (2010) Am Fam Physician 82:974-5[/conditional]


-------Blood Glucose-------


If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked? [select name="Q27" value="|Normal (Below 100)|Borderline High (100-125)|High (126 or higher)|don’t know/Not sure"]


-------Other Providers-------

Please list any specialists that you see along with their name, phone number and the last time that you saw them (approximately)
Cardiologist (Heart) [text name="speacialist_1" default=""]
Dentist (teeth) [text name="speacialist_2" default=""]
Endocrinologist (thyroid/diabetes) [text name="speacialist_3" default=""]
Gastroenterologist (stomach/liver) [text name="speacialist_4" default=""]
Nephrologist (Kidney) [text name="speacialist_5" default=""]
Oncologist (Cancer) [text name="speacialist_6" default=""]
Ophthalmologist (Eyes) [text name="speacialist_7" default=""]
Podiatrist (foot) [text name="speacialist_8" default=""]
Pulmonologist (Lungs) [text name="speacialist_9" default=""]
Psychiatrist (Mental Health) [text name="speacialist_10" default=""]
Orthopedics (Bone and Joint) [text name="speacialist_11" default=""]
Other [text name="speacialist_12" default=""]

When was your last Colonoscopy? [text name="other_1" default=""]
Where was your last Colonoscopy? [text name="other_2" default=""]

When was your last Pap smear (Women only)? [text name="other_3" default=""]
Where was your last Pap smear (Women only)? [text name="other_4" default=""]

When was your last Mammogram? [text name="other_5" default=""]
Where was your last Mammogram? [text name="other_6" default=""]
-------Physical Activity-------

How many days a week do you exercise?

How many minutes do you exercise per day?

How Intense is your typical exercise?


-------Tobacco Use-------

Do you Smoke?

Do you Vape?

Do you use smokeless Tobacco?

Are you interested in quitting?


-------Alcohol Use-------

Have you used alcohol in the past 7 days?

On days when you drank alcohol, how often did you have 4 or more drinks?

Do you ever drink and drive or ride with someone who is drinking and driving?


-------Nutrition-------

How many servings of fruits and vegetables do you eat per day?
(1 serving = 1 cup of fresh vegetables, ½ cup of cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball.)

How many servings of high fiber or whole grain food do you eat per day?
(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole-wheat pasta.)

How many servings of fried or high-fat foods do you eat per day?
(Examples: include fried chicken, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese or mayonnaise.)

How many sugar-sweetened drinks do you have per day?
(Examples: Pop, Kool-aid, sweet tea, coffee with sugar and cream.)


-------Depression-------

In the past 2 weeks, how often have you felt down, depressed or hopeless?

In the past 2 weeks, how often have you felt little interest or pleasure in doing things?

Have your feelings caused you distress or interfered with your ability to get along socially with family or friends?


-------Anxiety-------

In the past 2 weeks, how often have you felt nervous, anxious or on edge?

Are you able to control your worrying?


-------High Stress-------

How often is stress a problem for you in handling such things as your health, your family or social relationships and your finances?


-------Social and Emotional Support-------

How often do you get the social and emotional support you need:


-------Pain-------

In the past 7 days, how much pain have you felt?

What is your current pain level?


-------General Health-------

In general, would you say your health is?

How would you describe the condition of your mouth and teeth, including false teeth and dentures?


-------General Health-------

In the past 7 days have you needed help with daily living activities? Examples include: eating, getting dressed, bathing, walking, housekeeping, shopping, food preparation or taking your medications.

How many hours of sleep do you get a night?

Do you snore or has anyone told you that you snore?

Do you feel sleepy during the daytime?


-------General Health-------

What is your height without shoes?

Body Mass Index (BMI)

Height=((Height_ft)*(12))+(Height_in)
<-- Weight in pounds
BMI Calculations
Class --> classscore=(Weight)*(703)/((Height)*(Height));score>59.9999?'Super-super obesity or class V obesity':score>49.9999?'Super-obesity or class IV obesity':score>39.9999?'Extreme obesity or class III obesity':score>34.9999?'Obesity class II':score>29.9999?'Obesity class I':score>24.9999?'Overweight':score>18.4999?'Normal':score>16.4999?'Underweight':'Severely underweight'
BMI --> bmiscore1=score.toFixed(1)

display/hide references


-------Blood Glucose-------


If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked?


-------Other Providers-------

Please list any specialists that you see along with their name, phone number and the last time that you saw them (approximately)
Cardiologist (Heart)
Dentist (teeth)
Endocrinologist (thyroid/diabetes)
Gastroenterologist (stomach/liver)
Nephrologist (Kidney)
Oncologist (Cancer)
Ophthalmologist (Eyes)
Podiatrist (foot)
Pulmonologist (Lungs)
Psychiatrist (Mental Health)
Orthopedics (Bone and Joint)
Other

When was your last Colonoscopy?
Where was your last Colonoscopy?

When was your last Pap smear (Women only)?
Where was your last Pap smear (Women only)?

When was your last Mammogram?
Where was your last Mammogram?

Result - Copy and paste this output: