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Healthy Lifestyle Log - Week 5
Please complete this weekly log to track your physical, mental, and social health for the week.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
How many days last week did you eat more food than normal?
*
Choose
0
1
2
3
4
5
6
7
How many days did you consume (Fast or Restaurant Food)
*
None
1 to 3
4 to 5
6 to10
More than 10
What Snacks did you consume? (check all that apply)
*
No Snacks
Chips (ex.Hot Fries, Grippos etc)
Pastries (ex.Cookies, Honey Buns, Donuts, Cake)
Candy (ex Skittles, Candy Bars, Blow Pops, Fruities)
Fruit (ex.Bananas, Strawberries, Apples, Oranges, etc.)
Required
Did you drink more water than soft drinks or juice last week?
*
Yes
No
How many Stress-Free days did you have last week?
*
Choose
0
1
2
3
4
5
6
7
What kind of positive activity did you do to relieve stress during the week? (check all that applies)
*
Physical Fitness (ex. Sports,. Weight Training)
Leisure Activites (ex.Book Reading, Walking, Food, Cooking, Horse Play)
Recreational Activites (ex. Biking, Skating, Fishing, Hiking)
Technology Activties (ex. Cell Phone, Video Games)
Family and Friends Activites
Required
Does your family have any chronic diseases, such as
*
Heart Disease
Diabetes
High Blood Pressure
High Cholesterol
Cancer
Arthritis
Don't Know
Other:
Required
List something positive you did or happen last week
*
Your answer
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