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Physical Activity and Nutrition Behaviors Monitoring Form

  • 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.

Physical Activity and Nutrition Behaviors Monitoring Form
Modified Physical Activity and Nutrition Behaviors Monitoring Form (English)
Modified Physical Activity and Nutrition Behaviors Monitoring Form (Spanish)

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