260 San Jose St.
Salinas CA 93901
(831)757-8124
Spanish friendly staff
Amable personal bilingue

Staying Healthy Assessment 18 years – Adult

"*" indicates required fields

Patient’s Name (first & last)*
Date of Birth*
Today's Date*
Gender*
Relationship*

Specify if other

Please answer all the questions on this form as best you can. Circle “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.

1. Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk, or tofu?*
2. Do you eat fruits and vegetables every day?*
3. Do you limit the amount of fried food or fast food that you eat?*
4. Are you easily able to get enough healthy food?*
5. Do you drink a soda, juice drink, sports or energy drink most days of the week?*
6. Do you often eat too much or too little food?*
7. Are you concerned about your weight?*
8. Do you exercise or spend time doing activities, such as walking, gardening, swimming for ½ hour a day?*
9. Do you feel safe where you live?*
10. Have you had any car accidents lately?*
11. Have you been hit, slapped, kicked, or physically hurt by someone in the last year?*
12. Do you always wear a seat belt when driving or riding in a car?*
13. Do you keep a gun in your house or place where you live?*
14. Do you brush and floss your teeth daily?*
15. Do you often feel sad, hopeless, angry, or worried?*
16. Do you often have trouble sleeping?*
17. Do you smoke or chew tobacco?*
18. Do friends or family members smoke in your house or place where you live?*
19. In the past year, have you had: (Men: 5 or more alcohol drinks in one day?) - (Women 4 or more alcohol drinks in one day?)*
20. Do you use any drugs or medicines to help you sleep, relax, calm down, feel better, or lose weight?*
21. Do you think you or your partner could be pregnant?*
22. Do you think you or your partner could have a sexually transmitted infection (STI), such as Chlamydia, Gonorrhea, genital warts, etc.?*
23. Have you or your partner(s) had sex without using birth control in the past year?*
24. Have you or your partner(s) had sex with other people in the past year?*
25. Have you or your partner(s) had sex without a condom in the past year?*
26. Have you ever been forced or pressured to have sex?*
27. Do you have any other questions or concerns about your health?*