Simple Steps Monthly Self-Health Evaluation
Complete evaluations by the last day of the month to receive another entry into the monthly and grand prize drawings. If you prefer you can return this form at the Help Desk, at Simple Step classes, or by email to

Please do not write your name on these sheets. For your privacy, your name is NOT associated anywhere with the participation number on your tracker. This means we cannot provide your number should you lose it.

Participant Number (the number on the inside of your tracker) *
Your answer
Evaluation Month *
I eat 2 servings of fruit and 3 servings of vegetables each day.
I eat at least three meals a day.
I read the labels on the food I eat.
I limit the amount of salt I add to food.
I drink eight 8-ounce glasses of fluid a day (not counting sugary drinks).
I am active 30 minutes each day.
I have the up-to-date immunizations for my age.
My children under age 18 have up-to-date immunizations for their age.
I avoid smoking cigarettes, tobacco pipes, and cigars.
I avoid smoking e-cigarettes and vaping.
I limit how much I am around secondhand smoke using chewing tobacco.
I know my weight.
Your answer
I know my blood pressure.
Blood pressure reading
Your answer
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