logThe Healthy Lifestyle Questionnaire

The purpose of this questionnaire is to help you analyse your lifestyle behaviors and to help you in making decisions concerning good health and wellness for the future. Information presented on this Healthy Lifestyle Questionnaire is of a very personal nature. Your results are for your eyes only and for this reason it is for your information only. Answer each question as honestly as possible and use the scoring information to help you assess your lifestyle. Directions: Click the "CheckBox" below yes for "Yes" answer, leave unchecked for no. Score the questionnaire using the procedures that follow.

YOU CAN PRINT THIS PAGE FOR YOUR OWN RECORDS

Yes
1. I accumulate at least 30 minutes of moderate physical activity most days of the week (brisk walking, gardening, household chores). 17. I abstain from sex or limit sexual activity to a safe partner. Yes
Yes
2. I do vigorous activity that elevates my heart rate for 20 minutes at least 3 ariel a week. 18. I practice safe procedures for avoiding STD’s. Yes
Yes 3. I do exercises for flexibility at least three days a week. 19. I use seat belts and adhere to the speed limit when I drive. Yes
Yes 4. I do exercises for muscle fitness at least 2 days per week. 20. I have a smoke detector in my home and check it regularly to see it is working. Yes
Yes 5. I eat 3 regular meals each day. 21. I have had training to perform CPR if called on in an emergency. Yes
Yes 6. I select appropriate servings from the food guide pyramid each day. 22. I know the emergency phone number to call from mobile phones. Yes
Yes 7. I restrict the amount of fat in my diet. 23. I brush my teeth at least 2 ariel a day and floss at least once a day. Yes
Yes 8. I consume only as many calories as I expend each day. 24. I get an adequate amount of sleep each night. Yes
Yes 9. I am able to identify situations in daily life that cause stress. 25. I do regular self exams, have regular medical check ups, and seek medical advice when symptoms are present. Yes
Yes 10. I take time out during the day to relax and recover from daily stress. 26. When I receive advice and or medication from a physician, I follow up the advice and take the medication as prescribed. Yes
Yes 11. I find time for family, friends, and things I especially enjoy doing. 27. I read product labels and investigate their effectiveness before I buy them. Yes
Yes 12. I regularly perform exercise designed to relieve tension. 28. I avoid using products that have not been shown by research to be effective. Yes
Yes 13. I do not smoke or use other tobacco products. 29. I recycle paper, glass or aluminum. Yes
Yes 14. I do not abuse alcohol. 30. I practice environmental protection such as car pooling and conserving energy. Yes
Yes 15. I do not abuse drugs (prescription or illegal)
Yes 16. I take over the counter drugs sparingly and use them only according to directions. Overall Score – Total Yes Answers

Scoring and Interpreting your Results…

Give yourself 1 point for each yes answer. Add your scores for each of the lifestyle behaviors. To calculate your overall score, sum the totals for all lifestyles.

Physical Activity
Nutrition
Managing Stress
Avoiding Destructive Habits
Practice Safe Sex
Adopting Safety Habits
1
5
9
13
17
19
2
6
10
14
18
20
3
7
11
15
4
8
12
16
Total+
Total+
Total+
Total+
Total+
Total+
Knowing First Aid
Personal Health Habits
Using Medical Advice
Being an Informed Consumer
Protecting the Environment
Sum all Totals Overall Score
21
23
25
27
29
22
24
26
28
30
Total+
Total+
Total+
Total+
Total+
Total=
Interpreting Scores: Scores of 3 or 4 on the 4 item scales are generally positive lifestyles. For the 2 Item scales, a score of 2 would indicate the presence of positive lifestyles. An overall score of 26 or more would be a good indicator of healthy lifestyle behaviors. It is important to consider the following special note when interpreting scores. Special Note: Your scores on the Healthy Lifestyle Questionnaire should be interpreted with caution. First, all lifestyle behaviors do not pose the same risk. Using tobacco or abusing drugs has immediate negative affects on health and wellness, whilst others such as knowing first aid, may have only occasional use. You may score well on one item score but not on another. If one item indicates an unhealthy lifestyle in an area that poses a serious health risk, your lifestyle may appear to be healthier than it really is. For example you could get a 3 on the destructive habits scale and be a regular smoker. For this reason, the overall score may be deceiving and be comprehensively interpreted. Strategies for Change: You might want to make some notes concerning the healthy lifestyle areas in which you could make some change. A simple formula is to ask these 3 simple questions.
  1. What healthy lifestyle area can I improve?
  2. What strategies can I implement to have a positive influence over these healthy lifestyle area/s?
  3. What am I going to do now? You can refer to these notes later to see if you have made progress….