PIF Adult 3 Health Information Approximately how many hours of sleep do you get each night? When do you go to sleep at night? When do you get up? Rate your health: Excellent Good Average Poor Declining Your approximate: Weight: Height: Any weight changes recently? Do you have any chronic medical conditions? Please list and describe: List all important present and past illnesses, injuries, or handicaps: Date of last medical examination: What was the repor? Name and address of your physician? Are your presently taking medications? Yes No Have you ever used illegal or abused prescription drugs? Yes No How often do you consume alchohol? Daily Weekly Occasionally Very little None If the counselor belives that it would be helpful to see your psychiatric and/or medical reports, would you be willing to sign an information release form? If the counselor belives that it would be helpful to see your psychiatric and/or medical reports, would you be willing to sign an information release form? Yes No How many times per week do you exercise? What type of exercise? Do you have any dietary restrictions? How would you rate your overall eating habits? Poor Good Excellent If you are human, leave this field blank. Next Page