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Physical Activity and Nutrition Behaviors Monitoring Form
This form may be used by health department clinic staff and/or community- or school-based program staff to document and monitor select physical activity and nutrition behaviors that are key to maintaining a healthy weight. Information collected on this form may be entered on HSIS Screen 67 and local reports generated from HSIS Screen 19. A modified version of this form was developed by Healthy House of Catawba Valley Medical Center and translated into Spanish by a professional translator. The modified form is intended for use with children (or parents speaking on behalf of their children) and does not have data entry fields for HSIS ID # or Medicaid #. Otherwise, the questions about healthy behaviors are identical to those on the original form. |
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Eat Smart, Move More NC exists through the work of its many partner organizations |