Example Health Questionnaire

How healthy is your lifestyle?

Please answer each question by placing a tick in ONE of the 4 boxes.
Then, add up the number of ticks in each column and 'score' your questionnaire (see over the
page).
Finally, answer the 'What do you think and know about your health?' questions.
Question Always Usually Sometimes Never
Do you eat a balanced diet, low in sugar
and fat?
Do you eat 5 portions of vegetables
each day?
Do you eat some fruit each day?

Are you happy with your body size and

shape?
Do you drink about 6 glasses of water a
day?
Do you avoid drinking sugary drinks?

Do you get enough sleep (about 8-10

hours a night)?
Do you brush your teeth daily?

Do you go to the dentist regularly for a

check up?
Do you have a sensible balance
between rest, school and play?
Are you a non-smoker?

Are you calm and controlled?

Do you have a few good friends?

Do you do about 60 minutes of activity

each day?
Do you think you are a healthy person?

Do you think you are an active person?

Do you think you are fit?

Would you describe yourself as happy?

TOTAL NUMBER OF TICKS IN EACH

COLUMN 4 8 4 2