Name:

Grade Level:
Nearly
Always
Always Often Seldom Never
(5)
Wellness Lifestyle Questionnaire (4) (3) (2) (1)
1. I participate in vigorous aerobic activity for 20
minutes, 3x a day          
2. I participate in strength training exercises, 2 or
more days per week          
3.I perform flexibility exercises a minimum of 2x per
week.          

4. I maintain my recommended body weight.          

5. I eat 3 regular meals that include a wide variety of
food every day.          
6. I limit the amount of fats in my diet on most days
of the week.          

7. I eat fruits and vegetables every day          

8. I regularly avoid snacks, especially those high in
calories and fat.          
9. I readily recognize problems and act on it when I
am under excessive tension and stress.          
10. I am able to perform effective stress
management techniques.          
11. I have close friends and relatives with whom I
can discuss personal problems and approach for
help when needed.          
12. I spend most of my leisure time in wholesome
recreational activities.          
13. I can deal effectively with disappointments and
temporary feeling of sadness, loneliness, and
depression.          
14. I can work out emotional problems without
turning to alcohol or violent behavior.          
15. I associate with people who have a positive
attitude about life.          

16. I do not spend time and talent worrying about

failures.          
17. I wear a seatbelt, whenever I am in a car or
vehicle          
18. I do not drive under the influence of alcohol
nor read, write or send text messages while
driving.          
19. I avoid being alone in public places and staying
out until midnight.          
20. I always keep doors and windows locked,
especially when I am alone at home.          
21. I support community efforts to minimize
pollution.          
22. I use energy conservation tips and encourage
others to do the same          

23. I study in a clean environment          

24. I participate in recycling programs in my
community.