Name: ____________________________			Date: ________________


SCORECARD FOR EATING AND ACTIVITY


Date:		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|	
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
Breakfast 	|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|		
		|	|	|	|	|	|	|	|		
Snack		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
Lunch		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
Snack		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
Dinner		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
Snack		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
		|	|	|	|	|	|	|	|
30-min of 	|	|	|	|	|	|	|	|
moderate 	|	|	|	|	|	|	|	|
activity Y/N	|	|	|	|	|	|	|	|


Eating score; Total H’s ____ x 2.86 equals a score of  ____%  
 
Circle activity score:

Activity score; 5Y’s = 100%; 4Y’s = 90%; 3Y’s = 80%; 2Y’s = 70%; 1Y = 60%; 0Y’s = 0




Copyright © 1997 by  Healthy Changes.  4742 Liberty Rd. S. Box 303 Salem, Or. 
97302-5000 Reprinted with permission




Due Lab 7