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My Health Care Visit

Setting My Goals

What I Should Know

Hints for Reaching My Goals

Getting More Information

1. How many days a week do you do physical activities?

• 7 days
• 5–6 days
• 3–4 days
• 1–2 days
• 0 days

2. How much time do you spend being physically active on a typical day?

• More than 30 minutes
• 20–30 minutes
• Less than 20 minutes
• 0 minutes

3. What types of physical activity do you enjoy doing? (Check all that apply.)

• Walking
• Running
• Playing individual or team sports
• Swimming
• Dancing
• Climbing stairs
• Housecleaning
• Yard work
• Lifting weights
• Playing actively with children
• Others: ________________________________________________

4. What are some of the reasons that keep you from being as physically active as you’d like to be? (Check all that apply.)

• Lack of time.
• Don’t know how to be more physically active.
• Childcare is not available.
• Have a physical problem, pain, or disability.
• Don’t have a safe place to be physically active.
• Lack of energy.
• Don’t want to exercise in front of other people.
• Others: ________________________________________________

5. On a typical day, how often do you have foods from the milk group? For example, how often do you drink milk, add milk to your cereal, or eat yogurt or cheese?

• Three or more times a day
• Twice a day
• Once a day
• Less than once a day

6. On a typical day, how often do you eat foods from the meat and beans group, such as hamburger, chicken, turkey, fish, pork, peanut butter, eggs, nuts, dried beans, or tofu?

• Three or more times a day
• Twice a day
• Once a day
• Less than once a day

7. On a typical day, how often do you eat foods from the grains group, such as cereal, rice, pasta, breads, tortillas, couscous, bagels, pita bread, or crackers?

• Three or more times a day
• Twice a day
• Once a day
• Less than once a day

8. On a typical day, how often do you eat fruit or drink 100% fruit juice?

• Three or more times a day
• Twice a day
• Once a day
• Less than once a day

9. On a typical day, how often do you eat vegetables or drink 100% vegetable juice?

• Three or more times a day
• Twice a day
• Once a day
• Less than once a day

10. On a typical day, do you think about or do any of the following? (Check all that apply.)

• Think about the nutrients in my food.
• Try to eat nutrient-rich foods.
• Get the recommended nutrients through my food.
• Take vitamins or minerals.

11. What are some of the reasons that keep you from eating as healthy as you’d like to?

• Not sure which foods are healthy for me.
• There isn’t a grocery store in my neighborhood.
• Healthy food is expensive.
• Don’t have time to cook healthy food.
• Have to cook foods that my kids will eat.
• Others: ________________________________________________

“Since last year, I’ve gained a few pounds and don’t feel good with this extra weight. I started paying more attention to the things I eat, but knew that I had to start exercising. So I joined an exercise class at my church with a good friend. We kept each other going, and after 3 months, I’ve lost 10 pounds and found I have more energy. Not only that, but since I’ve had so much fun and made some great new friends, I’m going to keep up the classes.”
Linda
Springfield, Illinois