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Healthy Lifestyle | Exercise (Spouse 1)
My current physical activity level would be described as: (Select one)
Physically fit
Active
Sedentary
My goals to improve my activity level include: (Select all that apply)
Joining a gym or other active group
Checking if my other insurance will cover gym memberships
Monitoring my steps (via phone app or wearable device)
Other activity goals...
Notes regarding my goals and to maintain or improve my activity level:
If you are human, leave this field blank.
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Healthy Lifestyle | Socialize (Spouse 1)
The frequency of my meaningful social interactions would be described as: (Select one)
Frequent (daily meaningful interactions)
Moderate (family and some social gatherings; somewhat superficial)
Minimal (only essential interactions with others or with limited individuals)
My goals to increase my meaningful social interactions include: (Select all that apply)
Volunteering in charitable/religious service
Joining/engaging with hobby or civic groups
Other social interaction goals...
Notes regarding my goals to improve my meaningful social interactions:
If you are human, leave this field blank.
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Healthy Lifestyle | Eat Right (Spouse 1)
Name
Name
First
First
Last
Last
My current eating habits would be described as: (Select one)
Excellent
Fair
Poor
My goals to improve my eating habits include: (select all that apply)
Improve variety in my meals to include the proper nutritional balance for my age
Follow dietary instructions from my medical team
Monitor portion sizes
Decrease caloric intake
Limit amount of processed or fast food
Other dietary goals...
I would like to meet with a nutritionist:
Yes
No
Undecided
Notes regarding my goals and to maintain or improve my eating habits:
Submit
If you are human, leave this field blank.