Healthy Habits Child Healthy Habits Child Healthy Habits (Child) Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Date * (MM/DD/YYYY) Patient * DOB * (MM/DD/YYYY) Questions 1. My child eats this many servings of veggies a day (a serving is about the size of your fist) * 0-1 servings 2-3 servings 3-4 servings more than 4 servers 2. My child eats this many servings of fruits a day (a serving is about the size of your fist) * 0-1 servings 1-2 servings 3-4 servings more than 4 servings 3. My child eats out * More than 4 times a week 3-4 times a week 1-2 times a week 0-1 time a week 4. My child is active * Not very often Less than 30 minutes a day 30-60 minutes a day More than 60 minutes a day 5. My child has sweet drinks soda, sweet tea, 100% fruit juice, sports drinks, other fruit drinks) * More than 3 cups a day 2 cups a day 1 cup a day Not very often 6. My child watches television, plays video games, spends (non-school related) time on the computer, table, or cell phone * More than 2 hours a day 1-2 hours a day 30-60 minutes a day Not very often 7. Most nights, my child sleeps * Less than 7 hours 7-8 hours 9-10 hours More than 10 hours 8. If you could work on one healthy habit, which would it be? * Make half your plate veggies and fruits Limit screen time Be more active Drink more water and limit sugary drinks Get the right amount of sleep I am not ready to work on a healthy habit Submit If you are human, leave this field blank.
