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These forms are to enhance patient and provider
visits. They are designed to start a dialogue between patient and
provider regarding improving health behaviors. The health prescription
offers ideas related to physical activity, body image and food and
eating.
Food and Physical Activity
for Health Tip Sheet (PDF format)
This sheet includes
directions for health care providers to use the two forms. It also
shares ideas for making large patients feel welcome.
Food and Physical Activity
Habit Inventory (PDF format)
This form is completed by
the patient. Patients complete the form providing an overview of their
physical activity and eating habits.
Food and Physical Activity
for Health (PDF format)
Using the habit inventory, this form becomes a prescription for health.
The form can help patients set some health-related goals and includes
ideas for meeting those goals.
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