Patient Name(Required) Email(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required) Marital Status(Required)SingleMarriedDivorcedCell Phone(Required) Emergency Contact(Required) Address(Required) City(Required) State(Required) Zipcode(Required) Residence Type(Required) Employment Status(Required) Physical Activity - Exercise Q & A for Your AssessmentIn The Past 7 Days, How Many Did You Exercise?(Required)Please enter a number from 0 to 7.On Days When You Exercised, For How Long Did You Exercise (In Minutes) ?(Required)Please enter a number from 0 to 60.HiddenTotal minutes per weekHow Intense Was Your Typical Exercise? Light (Like Stretching Or Slow Walking) Moderate (Like Brisk Walking) Heavy (Like Jogging Or Swimming) Very Heavy (Like Fast Running Or Stair Climbing) I Am Currently Not Exercising Recommendation:(Required) Patient is exercising as per recommendation and CDC recommendations for Physical activity given. Recommendation:(Required) Patient counseled to exercise - recommend 150 minutes of moderate activity per week. CDC recommendations for Physical activity given Δ
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