Lifestyle/Readiness for Change Assessment This form asks you a variety of questions about your lifestyle habits. This questionnaire should take about 10 minutes. Fill in the information requested, or place a check in the appropriate space. We thank you for your time and effort in completing this questionnaire. Please be open and honest with your answers. Personal Information Today s Date: / / Date of Birth: / / Height: Your Name: Gender (Circle One): Male Female Weight: Health Health is a state of complete physical, mental, social, and spiritual well-being, not merely the absence of disease and infirmity. 1. Please rate how important your health is to you: Not Important Very Important 2. In general, compared to other persons your age, rate how healthy you are: Not Healthy Very Healthy 3. Do you think there is anything you personally should do to improve your health? Yes No If yes, check each item below that you think is important for you to improve. Improve eating habits Lose Weight Stop Smoking Gain Weight Improve muscle tone Improve muscle strength Improve cardiovascular health/endurance Reduce drug use/medications Cut down on alcoholic beverages Reduce stress levels Other (Specify)
Physical Activity and Exercise: Physical activity is any movement of the body produced by skeletal muscles, while exercise is physical activity that is planned and repeated for the purpose of improving health and fitness. 4. Please rate how important regular physical activity & exercise is to you: Not at all important 5. In general, compared to other persons your age, rate how physically active you are: Not at all physically active Extremely active 6. How long have you exercised or played sports regularly? I do not exercise regularly less than 1 year 1 to 2 years 2 to 5 years 5 to 10 years more than 10 years 7. Outside of your normal work or daily responsibilities, how often do you engage in moderateto-intense exercise? (Moderate-to-intense exercise is defined as activity that substantially increases your breathing and heart rate and makes you sweat for at least 20 minutes through such activities as brisk walking, cycling, swimming, jogging, aerobic dance, stair climbing, rowing, basketball, racquetball, vigorous yard work, etc.). 5 or more times per week 3 to 4 times per week 1 to 2 times per week Less than 1 time per week Seldom to never 8. How much hard physical activity is required to your job? A great deal A moderate amount A little None Physical Fitness Physical fitness is the ability to perform moderate-to-vigorous levels of physical activity without undue fatigue and the capability of maintaining such ability throughout life. Physical fitness has three major components: optimal body fat, good heart and lung endurance, and strong, enduring muscles. 9. Please rate how important physical fitness is to you: Very important 10. In general, compared to other persons your age, rate how physically fit you are: Not physically fit Extremely physically fit
Nutrition Good nutrition is important to health at all stages of life. Healthful diets contain the amounts of essential nutrients and energy needed to prevent nutritional deficiencies and excesses. Healthful diets also provide the right balance of carbohydrate, fat, and protein to reduce risks for chronic diseases (e.g., heart disease and cancer). Healthful diets consist of a variety of foods that are available, affordable, and enjoyable. Are you currently following a specific diet? Y / N If so please describe: Body Weight Body weight can be subdivided into fat weight (the weight of all the fat tissue) and fat-free weight (the weight of the remaining lean tissue). In order to maintain a healthy body weight and avoid an increase in body fat, people must balance the amount of energy in food with the amount of energy the body uses (especially physical activity). 11. Please rate how important a healthy body weight is to you: 12. In general, rate how close you are to your ideal body weight (the weight that you think is health for you): Not close Exactly Right 13. How much weight would you like to lose or gain to reach your ideal weight? Pounds to lose: lbs Pounds to gain: lbs Don t want to gain or lose 14. Which of the following are you NOW trying to do? Lose weight Stay about the same 15. How do you rate your outlook on life? Gain weight Not trying to do anything Very pessimistic 16. How do you rate your interest in the world around you? Very optimistic Not interested Very interested
17. How stressful do you rate your life? Not stressful Very stressful 18. How frequently do you become angry or upset over events in your life? Never Often 19. How satisfied are you with your life? Not satisfied Very satisfied Social Health Social health refers to the ability to interact effectively with other people and with the social environment (e.g., social groups and networks), as well as the ability to engage in satisfying personal relationships. 20. Please rate how important good social health is to you: 21. In general, rate your social health: Not healthy Extremely healthy 22. How important are your friends and family when making life decisions? Substance Abuse Substance abuse is defined as the excessive use of a substance, especially one that may modify body functions, such as alcoholic drinks, tobacco, and drugs. 23. How would you describe your cigarette smoking habits? Never smoked Use to smoke Still smoke How many months has it been since you last smoked? On average, how many cigarettes do you smoke per day? 24. How many alcoholic drinks do you consume? (A drink is a glass of wine, a wine cooler, a bottle or can of beer, a shot glass of liquor, or a mixed drink.) Never use alcohol Less than 1 per week 1 to 6 per week 1 per day 2 to 3 per day more than 3 per day
25. Think back over the last month. How many times (if any) have you had 5 or more drinks on one occasion? None Once Twice 3 to 5 times 6 to 9 times 10 or more times Personal Health and Safety 26. When did you last: 6 months 6 to 12 mo 1 to 2 yrs Never See a doctor for a physical? Check your blood pressure? What was your blood pressure? / Check your cholesterol? What was your total? LDL? HDL? Check your resting heart rate? What was your resting heart rate? 27. Have you EVER been told by a doctor or other health professional that you have: Yes No Hypertension (high blood pressure)? High blood cholesterol? Diabetes? 28. Did either of your parents, or one of your siblings, before the age of 60, have or die from: Yes No Coronary heart disease? Stroke? Cancer? Diabetes? 29. On average, how many hours of sleep do you get in a 24-hour period? Less than 5 5 to 6.9 7 to 9 more than 9 30. How often do you get insufficient rest so that you are unable to function efficiently? less than weekly Usually 1 night per week 2 or 3 nights a week 4 or more nights a week Thank you and congratulations, you are on your way to a healthier lifestyle!