Form DHCS4035 B "Youth Nutrition and Activity Assessment (Ages 8 - 19)" - California

What Is Form DHCS4035 B?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS4035 B by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS4035 B "Youth Nutrition and Activity Assessment (Ages 8 - 19)" - California

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Youth Nutrition and Activity Assessment
(Ages 8 - 19)
Office use only
Provide additional information about your food, activity and habits:
Complete assessment below
using all information provided:
Eating Habits
Eating Habits
Do you eat or drink the following meals? Circle one answer per meal.
Overall diet adequate
Yes
No
Breakfast
Always
Usually
Occasionally
Never
3 meals and snacks
Yes
No
Morning snack
Always
Usually
Occasionally
Never
High iron foods
Yes
No
Lunch
Always
Usually
Occasionally
Never
Calcium foods
Yes
No
Afternoon snack
Always
Usually
Occasionally
Never
5 or more fruits/vegetables Yes
No
Dinner
Always
Usually
Occasionally
Never
Adequate fluids
Yes
No
Evening Snack
Always
Usually
Occasionally
Never
Exercise/Physical Activity
Exercise/Physical Activity
How many hours a day do you?
Limits use of TV, phone, internet, video
or computer games to ≤ 1-2 hours/day
Watch TV
_____ hours/day
Use a smart phone
_____ hours/day
Yes
No
Play video/computer games
_____ hours/day
Goal set:
________________________
Use the internet
_____ hours/day
Do you participate in physical education classes at school? Yes No
Engages in physical activity
(60 minutes/day or more) Yes
No
Circle all that you participate in:
Walking
Running
Bicycling
Swimming
Goal set: ______________________
Dance
Yoga
Martial Arts
Rollerblading
Basketball
Softball
Soccer
Volleyball
Referral made
Yes
No
Other activities or team sports: _____________________________
Referred to: ___________________
How often are you physically active?
_____ times/week
_____ minutes/day
Weight/Body Image
Weight/Body Image
BMI %ile ________ Date ____________
Circle one. Are you trying to?
Stay the same Lose weight
Gain weight
Not concerned
 BMI between 5th and 85th %iles
Do you eat less to control your weight?
Yes
No
 BMI ≤ 5th %ile
Explain: ________________________________________________
 BMI between 85th and 95th %iles
Have you ever made yourself vomit?
Yes
No
 BMI ≥ 95th %ile
If yes, how often? __________ When was the last time? ________
Do you ever “binge” eat?
Yes
No
Signs of eating disorder
Yes
No
If yes, how often? __________ When was the last time? ________
Counseling given
Yes
No
Circle any of the following that you use:
Topics: _______________________
Diet pills
Laxatives
Multivitamins
Calcium
Iron
Vitamin D
Goal set: ______________________
Protein powder
Nutrition supplements
Steroids
Referral made
Yes
No
What, if any, other products do you use?
Explain: ________________________________________________
Referred to: ___________________
DHCS 4035 B (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties
Youth Nutrition and Activity Assessment
(Ages 8 - 19)
Office use only
Provide additional information about your food, activity and habits:
Complete assessment below
using all information provided:
Eating Habits
Eating Habits
Do you eat or drink the following meals? Circle one answer per meal.
Overall diet adequate
Yes
No
Breakfast
Always
Usually
Occasionally
Never
3 meals and snacks
Yes
No
Morning snack
Always
Usually
Occasionally
Never
High iron foods
Yes
No
Lunch
Always
Usually
Occasionally
Never
Calcium foods
Yes
No
Afternoon snack
Always
Usually
Occasionally
Never
5 or more fruits/vegetables Yes
No
Dinner
Always
Usually
Occasionally
Never
Adequate fluids
Yes
No
Evening Snack
Always
Usually
Occasionally
Never
Exercise/Physical Activity
Exercise/Physical Activity
How many hours a day do you?
Limits use of TV, phone, internet, video
or computer games to ≤ 1-2 hours/day
Watch TV
_____ hours/day
Use a smart phone
_____ hours/day
Yes
No
Play video/computer games
_____ hours/day
Goal set:
________________________
Use the internet
_____ hours/day
Do you participate in physical education classes at school? Yes No
Engages in physical activity
(60 minutes/day or more) Yes
No
Circle all that you participate in:
Walking
Running
Bicycling
Swimming
Goal set: ______________________
Dance
Yoga
Martial Arts
Rollerblading
Basketball
Softball
Soccer
Volleyball
Referral made
Yes
No
Other activities or team sports: _____________________________
Referred to: ___________________
How often are you physically active?
_____ times/week
_____ minutes/day
Weight/Body Image
Weight/Body Image
BMI %ile ________ Date ____________
Circle one. Are you trying to?
Stay the same Lose weight
Gain weight
Not concerned
 BMI between 5th and 85th %iles
Do you eat less to control your weight?
Yes
No
 BMI ≤ 5th %ile
Explain: ________________________________________________
 BMI between 85th and 95th %iles
Have you ever made yourself vomit?
Yes
No
 BMI ≥ 95th %ile
If yes, how often? __________ When was the last time? ________
Do you ever “binge” eat?
Yes
No
Signs of eating disorder
Yes
No
If yes, how often? __________ When was the last time? ________
Counseling given
Yes
No
Circle any of the following that you use:
Topics: _______________________
Diet pills
Laxatives
Multivitamins
Calcium
Iron
Vitamin D
Goal set: ______________________
Protein powder
Nutrition supplements
Steroids
Referral made
Yes
No
What, if any, other products do you use?
Explain: ________________________________________________
Referred to: ___________________
DHCS 4035 B (05/16) Adapted from the CHDP Programs of Orange County and San Bernardino Counties