THE HEALTHY LIFESTYLE QUESTIONNAIRE

NAME: EAZEL DONN O. VILLAMATER GRADE AND SECTION: 12- FAITH DATE: 09/24/21

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. Answer each question as honestly as possible and use the scoring
information to help you assess your lifestyle.

DIRECTIONS: Tick the box to answer yes. If you answer “no,” make no mark. Score
the procedures that follow.
☒1. I accumulate 30 minutes of moderate physical activity most days of the week
(brisk walking, stair climbing, yard work, or home chores).
☒2. I do vigorous activity that elevates my heart rate for 20 minutes at least 3 days
a week.
☒3. I do exercises for flexibility at least 3 days a week.

☒4. I do exercises for muscle fitness at least 2 days a week.

☒5. I eat three regular meals a day.

☒6. I select appropriate servings from the major food groups each day.

☒7. I restrict the amount of fat in my diet.

☐8. I consume only as many calories as I expend each day.

☒9. I am able to identify situations in daily life that cause stress.

☒10. I take time out during the day to relax and recover from daily stress.

☒11. I find time for family, friends, and things I especially enjoy doing.

☒12. I regularly perform exercises designed to relieve tension.

☒13. I do not smoke or use other tobacco products.

☒14. I do not abuse alcohol.

☒15. I do not abuse drugs (prescription or illegal)

☒16. I take over-the-counter drugs sparingly and use them only according to
directions.
☒17. I abstain from sex or limit sexual activity to a safe partner.

☒18. I practice safe procedures for avoiding sexually transmitted infections (STI).

☒19. I practice safety protocol whenever I go outside.

☒20. I have smoke detector in my house and check it regularly to see that it is
working.
 ☒21. I have had training to perform CPR if called on in an emergency.

☐22. I can perform the Heimlich maneuver effectively if called on in an emergency.

☒23. I brush my teeth at least two times a day and floss at least once a day.

☐24. I get an adequate amount of sleep each night

☒25. I do regular self-exams, have regular medical check-ups, and seek medical
adv6ice when symptoms are present.
☒26. When I receive advice and/or medication from a physician, I follow the advice
and take the medication as prescribed.
☒27. I read product labels and investigate their effectiveness before I buy them.

☒28. I avoid using products that have not been shown by research to be effective.

☒29. I recycle paper, glass, and aluminum.

☒30. I practice environmental protection, such as carpooling and energy

conservation.

27 OVERALL SCORE-Total “Yes” Answers

Scoring: Give yourself 1 point for each “yes” answer. Add your scores for each
lifestyle behavior. To calculate your overall scores, sum the total of all your lifestyles.
1. 5. 9. 13. 17. 19. 21. 23. 25. 27. 29.
2. 6. 10. 14. 18. 20. 22. 24. 26. 28. 30.
3. 7. 11. 15.
4. 8. 12. 16.
=4 =3 =4 =4 =2 =2 =1 =1 =2 =2 =2 =27
Avoiding Destructive

Practicing Safe Sex

Being an Informed

Sum all Totals for

Knowing First Aid
Adopting Safety

Personal Health
Managing Stress
Physical Activity

Overall Scores
Using Medical

Protecting the
Environemt
Costumer
Nutrition

Habits

Advice
Habits

Habits

Healthy Lifestyle Ratings

Conclusions and Implications:
Rating Two-Item Four-Item Overall
Scores Scores Scores With the help of this questionnaire, I
have determined that I have a positive
Positive 2 3 or 4 26 to
lifestyle because I have an overall score
lifestyles 30
of 27.
Consider Less Less than Less
changes than 2 3 than 26