NHS Form

    Full Name

    Email

    Date

    1. How many portions of fruit do you eat each day?

    2. How many portions of vegetables do you eat each day?

    3. How many glasses of water do you drink each day?

    4. I eat ______ portions of wholegrain carbohydrates (e.g. bread, pasta, porridge, reduced sugar cereal, oatcakes, and brown rice) each day?

    5. I eat ______ portions of protein (e.g. meat, nuts, fish, eggs, beans, tofu, peanut, butter and cheese) each day?

    6. I eat ______ portions of oily fish each week (e.g. mackerel, pilchards, sardines or salmon. White, battered fish, or tune doesnt count as an oily fish)

    7. I eat ______ portions of calcium (e.g. dairy milk, cheese, yoghurt, green leafy vegetables, peas, fortified non-dairy milks, and tofu) rich foods each day?

    8. I eat ______ portions of high sugar/high fat food, snacks, or drinks (e.g. cakes, biscuits, chocolate bars, muffins, high sugar cereal, fizzy drinks, sausages, bacon, crisps) each day?

    9. I add salt to my meals (this includes during cooking or at the table)

    10. I eat breakfast

    11. I am active ______ minutes each day

    12. I am sat down for ______ hours each day

    13. I am feel happy

    14. Being healthy is

    15. How important is my heart to me

    16. I know how to keep my heart healthy

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