Who Is It For?
Health department clinic staff, community- or school-based program staff.
How Do You Get It?
This resource is distributed electronically and can be downloaded on this page.
How Is It Used?Provides a way to document and monitor select physical activity and nutrition behaviors important to maintaining a healthy weight.
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.