OUR LADY OF LOURDES COLLEGE

5031 GEN. T. DE LEON, VALENZUELA CITY

Greetings. We are students from STEM 12-1, engaged in a research endeavor

titled "A Comparative Study Between the Healthy Lifestyles of Smokers and Non-
Smokers in Gen. T. De Leon." The primary aim of this research study is to collect
pertinent data on our chosen topic. We assure you that all responses will be treated with
utmost confidentiality. Your participation is integral to the achievement of our study
objectives. Thank you for contributing to the success of our research. Thank you for
taking the time to consider participating in our research survey. We appreciate your
willingness to contribute to our study on "A Comparative Study Between the Healthy
Lifestyles of Smokers and Non-Smokers in Gen. T. De Leon.”

CONSENT FORM
As a component of our research, we seek your consent as a participant in our study.
I ______________________, in my capacity as a Non-Smoker in Gen. T. De Leon,
Valenzuela City formally acknowledge my voluntary participation as a respondent in
the research study titled "A Comparative Study Between the Healthy Lifestyles of
Smokers and Non-Smokers in Gen. T. De Leon." conducted at Our Lady of Lourdes
College. I am cognizant that my engagement in this study is voluntary, and I can
withdraw from participation at any given point.

__________________
Signature

Section 1: Demographic Profile

Name (Option): _________________ Age: ____ Male: ___ Female: ___
Employment Status: Employed __ Unemployed __

Section 2: Number of sticks of cigarettes consumed per day:

PART II:
The following questions are designed to measure quantitative data on your opinion and
attitude in the particular study. Please read each statement carefully and indicate the
degree to which you agree or disagree with it using the following scale:

1 = Strongly Disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly Agree
There are no right or wrong answers, and we encourage you to be honest and truthful in
your responses. Your answers will be kept confidential and used for research purposes
only.

SECTION 3: PHYSICAL FITNESS 1 2 3 4 5

1. The respondents currently participate in physical activities

that elevate their heart rate (e.g., brisk walking, jogging, cycling).

2. The respondents do the long-term health goals differ between

smokers and non-smokers.

3. The respondents believe that they can resist the pressure to

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smoke, even in social situations.

4. The respondents believe that their habit is below average

compared to other smokers.

5. The respondent believes that quitting smoking would

significantly improve their health and well-being.

6. The respondent generally feels satisfied with their overall

health and well-being.

7. The respondent believes that regular physical activity is

essential for maintaining a healthy lifestyle

8. The respondents feel physically tired or drained most of the

time.

9. The respondent is satisfied with their overall level of physical

fitness.

10. The respondents regularly incorporate strength training

exercises into their fitness routine.

SECTION 4: PRACTICES OF SMOKING PREVALENCE 1 2 3 4 5

1. The respondents believe that parents and families play a

crucial role in preventing youth smoking through open
communication and setting clear expectations.

2. The respondents do the long-term health goals differ

between smokers and non-smokers.

3. The respondents believe that they can resist the pressure to

smoke, even in social situations.

4. The respondents believed that their habit is below average

compared to other smokers.

5. The respondents believe that quitting smoking would

significantly improve their health and well-being.

6. The respondent generally feels satisfied with their overall

health and well-being

7. The respondent smokes cigarettes on a daily basis.

8. The respondents have made efforts to reduce or quit

smoking.

9. The respondent encountered obstacles in reducing or quitting

smoking.

10. The respondents do the long-term health goals differ

between smokers and non-smokers.
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SECTION 5: HEALTHY LIFESTYLE 1 2 3 4 5

1. The respondent considers their diet to be balanced and

nutritious.

2. The respondent prioritizes consuming whole, unprocessed

foods over processed or packaged foods.

3. The respondent feels knowledgeable about making healthy

food choices.

4. The respondent feels physically capable of participating in a

variety of physical activities.

5. The respondents prioritize consuming fruits and vegetables

with every meal.

6. The respondents generally feel satisfied with their overall

health and well-being.

7. The respondent limits the intake of sugary drinks and opt for
water or unsweetened beverages.

8. The respondents feel satisfied with my overall dietary habits.

9. The respondent maintains a regular eating schedule and

avoids skipping meals.

10. The respondents limit the consumption of processed foods,

sugary drinks, and unhealthy fats.