Lifestyle Assessment
Email address *
Exercise & Fitness
I engage in moderate exercise, such as brisk walking or swimming, for the equivalent of at least 150 minutes per week. *
Never
Almost Always
I do exercises to develop muscular strength and endurance at least twice a week. *
Never
Almost Always
I spend some of my leisure time participating in individual, family, or team activities, such as gardening, bowling, or softball. *
Never
Almost Always
I maintain a healthy body weight, avoiding overweight and underweight. *
Never
Almost Always
Nutrition
I eat a variety of foods each day, including seven or more servings of fruits and/or vegetables. *
Never
Almost Always
I limit the amount of saturated and trans fats in my diet. *
Never
Almost Always
I avoid skipping meals *
Never
Almost Always
I limit the amount of salt and added sugars I eat. *
Never
Almost Always
Tobacco Use
I avoid smoking cigarettes *
Never
Almost Always
I avoid using a pipe or cigars. *
Never
Almost Always
I avoid spit tobacco. *
Never
Almost Always
I limit my exposure to environmental tobacco smoke. *
Never
Almost Always
Alcohol and Drugs
I avoid alcohol, or I drink no more than one (women) or two (men) drinks a day. *
Never
Almost Always
I avoid using alcohol or other drugs as a way of handling stressful situations or the problems in my life. *
Never
Almost Always
I am careful not to drink alcohol when taking medications (such as cold or allergy medications) or when pregnant. *
Never
Almost Always
I read and follow the label directions when using prescribed and over-the-counter drugs. *
Never
Almost Always
Emotional Health
I enjoy being a student, OR I have a job or do other work that I enjoy. *
Never
Almost Always
I find it easy to relax and express my feelings freely. *
Never
Almost Always
I manage stress well. *
Never
Almost Always
I have close friends, relatives, or others whom I can talk to about personal matters and call on for help when needed. *
Never
Almost Always
I participate in group activities (such as community or church organizations) or hobbies that I enjoy. *
Never
Almost Always
Safety
I wear a safety belt when riding in a car. *
Never
Almost Always
I avoid driving while under the influence of alcohol or other drugs. *
Never
Almost Always
I obey traffic rules and the speed limit when driving. *
Never
Almost Always
I read and follow instructions on the labels of potentially harmful products or substances, such as household cleaners, poisons, and electrical appliances. *
Never
Almost Always
I avoid using a cell phone while driving. *
Never
Almost Always
Disease Prevention
I know the warning signs of cancer, heart attack, and stroke. *
Never
Almost Always
I avoid overexposure to the sun and use sunscreen. *
Never
Almost Always
I get recommended medical screening tests (such as blood pressure and cholesterol checks and Pap tests), immunizations, and booster shots. *
Never
Almost Always
I practice monthly skin and breast/testicle self-exams. *
Never
Almost Always
I am not sexually active, OR I have sex with only one mutually faithful, uninfected partner, OR I always engage in safer sex (using condoms), and I do not share needles to inject drugs. *
Never
Almost Always
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