The Healthy Lifestyle Questionnaire

The purpose of this questionnaire is to help you analyze

your lifestyle behaviors and to help you make decisions
concerning good health and wellness for the future. Information
on this Healthy Lifestyle Questionnaire is of a personal nature.

Directions: Place an X over the "yes" to answer yes. If you

answer "no" make no mark. Score the questionnaire using the
procedures that follow.

1. I accumulate 30
minutes of moderate
physical activity most 10. I take time out during
YES days of the week (brisk YES the day to relax and
walking, stair climbing, recover from daily stress.
yard work, or home
chores)

2. I do vigorous activity 11. I find time for

that elevates my heart family, friends, and
YES YES
rate for 20minutes at things I especially enjoy
least 3 days a week. doing.

3. I do exercises for 12. I regularly perform

YES flexibility at least 3 YES exercises designed to
days a week. relieve tension.

4. I do exercises for
13. I do not smoke or use
YES muscle fitness at least 2 YES
other tobacco products.
days a week.

5. I eat three regular 14. I do not abuse

YES YES
meals each day. alcohol.

6. I select appropriate
15. I do not abuse drugs
YES servings from the major YES
(prescription or illegal).
food groups each day.

16. I take over-the-

7. I restrict the amount counter drugs sparingly
YES YES
of fat in my diet. and use them only
according to direction.

8. I consume only as many 17. I abstain from sex or

YES calories as I expend each YES limit sexual activity to a
day. safe partner.

18. I practice safe

9. I am able to identify
procedure for avoiding
YES situations in daily life YES
sexually transmitted
that cause stress.
infections(STI).
 25. I do regular self-
19. I use seat belts and exams, have a regular
YES adhere to the speed limit YES medical checkups, and seek
when I drive. medical advice when
symptoms are present.

26. When I receive advice

20. I have a smoke
and/or medication from a
detector in my house and
YES YES physician, I follow the
check it regularly to see
advice and take the
that it is working.
medication as prescribed.

27. I read product labels

21. I have had training
and investigate their
YES to perform CPR if called YES
effectiveness before buy
on in an emergency.
them.

22. I can perform the 28. I avoid using products

Heimlich maneuver that have not been shown
YES YES
effectively if called on by research to be
in an emergency. effective.

23. I brush my teeth at

least two times a day and 29. I recycle paper, glass
YES YES
floss at least once a and aluminum.
day.

30. I practice
24. I get an adequate
environmental protection,
YES amount of sleep each YES
such as carpooling and
night.
energy conservation.
 Scoring: The Healthy Lifestyle Questionnaire
Give 1 point for each "yes" answer. Add the scores for each
of the lifestyle behaviors. In calculating the scores, sum the
totals for all lifestyles.

Physical 1. 2. 3. 4. Total:
Activity

Nutrition 5. 6. 7. 8. Total:

Managing 9. 10. 11. 12. Total:

Stress

Avoiding 13. 14. 15. 16. Total:

Destructive
Habits

Practicing 17. 18. Total:

Safe Sex

Adopting 19. 20. Total:

Safety
Habits

Knowing 21. 22. Total:

First Aid

Personal 23. 24. Total:

Health
Habits

Using 25. 26. Total:

Medical
Advice

Being an 27. 28. Total:

Informed
Customer

Protecting 29. 30. Overall

the score:
Environment

Interpreting Scores:

An overall score of 26 or more is a good indicator of

healthy lifestyle behaviors. Less than 26 in overall score
indicator for the need for improvement or consider changes.