Healthy Lifestyle: A Self-Assessment

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All information received on this form will be treated as strictly confidential. Please fill
out the forms completely and accurately. This information will help you better understand the essence of healthy living

Month, day, year____/____/_____ *

YYYY

Your age (years) *

Sex *

male

female

Your study specialty *

About the survey

Everyone wants good health. However, many people do not have habits that contribute to health, well-being,and vitality. Health professionals now describe lifestyle as one of the most important factors affecting health.This lifestyle assessment, adapted from one created by the U.S. Public Health Service, will help you evaluate how well you are doing at managing the factors that strongly affect your present and future health. For each statement choose the answer that best describes your behavior.

Smoker *

Yes

Exercise/Fitness

I engage in vigorous exercise (examples include jogging, swimming,brisk walking, cycling) for 20–60 minutes, 3–5 days a week. *

Almost, always

Sometimes

Never

I do exercises to develop muscular strength and endurance(examples include weight lifting, using exercise bands, pushups,abdominal curls) at least twice a week. *

Almost, always

Sometimes

Never

I do exercises (stretching) to develop flexibility at least twice a week (10 minutes, 3-5 days per week) *

Almost, always

Sometimes

Never

I maintain a healthy weight, avoiding overweight and underweight. *

Almost, always

Sometimes

Never

Nutrion

I eat a variety of foods each day, including five or more servings of fruits and/or vegetables *

Almost, always

Sometimes

Never

I limit the amount of total fat, cholesterol, saturated fat, and transfats in my diet. *

Almost, always

Sometimes

Never

I limit the amount of salt and sugar I eat. *

Almost, always

Sometimes

Never

I intentionally include whole grains and dairy/calcium products in my diet every day. *

Almost, always

Sometimes

Never

Stress

I enjoy being a student, and do other work that I enjoy. *

Almost, always

Sometimes

Never

I find it easy to relax and express my feelings freely. *

Almost, always

Sometimes

Never

I use healthy coping skills for managing the stress in my life. *

Almost, always

Sometimes

Never

I have close friends, relatives, or others I can talk to about personal matters and call on for help when needed. *

Almost, always

Sometimes

Never

I participate in group activities (such as community, school,church organizations) and/or hobbies that I enjoy. *

Almost, always

Sometimes

Never

Alcohol and Drugs

I avoid alcohol or I drink no more than 1 (women) or2 (men) drinks a day. *

Almost, always

Sometimes

Never

I avoid using alcohol or other drugs as a way of handling stressful situations or problems in my life. *

Almost, always

Sometimes

Never

I am careful not to drink alcohol when taking medications(such as for colds, allergies, pain) or when pregnant. *

Almost, always

Sometimes

Never

I read and follow the label directions when using prescribedand over-the-counter drugs. *

Almost, always

Sometimes

Never

Safety

I wear a seat belt while driving or riding in a car. *

Almost, always

Sometimes

Never

I avoid driving while under the influence of alcohol or other drugs. *

Almost, always

Sometimes

Never

I obey traffic rules and the speed limit when driving. *

Almost, always

Sometimes

Never

I make sure I am fully alert when driving (not drowsy, not talkingon a cell phone, not reading, not putting on makeup, etc.). *

Almost, always

Sometimes

Never

I am careful when using potentially hazardous products or substances such as chemicals, poisons, household cleaners,and electrical appliances. *

Almost, always

Sometimes

Never

Disease Prevention

I know the warning signs of cancer, heart attack, and stroke. *

Almost, always

Sometimes

Never

I avoid over exposure to the sun and use sunscreen. *

Almost, always

Sometimes

Never

I get recommended age-appropriate medical screening tests(examples include blood pressure and cholesterol checks, Pap tests,mammograms, dental exams), immunizations, and booster shots. *

Almost, always

Sometimes

Never

I get 7–9 hours of sleep most nights. *

Almost, always

Sometimes

reti

I am not sexually active or I have sex with only one mutually faithful partner or I use condoms, and I do not share needles to inject drugs. *

Almost, always

Sometimes

Never

Assessing Your Wellness

Wellness is an active process of becoming aware of and making choices towards a healthy and fulfilling life. It is more than being free from illness, it is a dynamic process of change and growth. A good or satisfactory condition of existence; a state characterized by health, happiness, and prosperity; welfare.

“Wellness is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” – The World Health Organization.

Physical Dimension

Physical wellness relates to maintaining a healthy body and seeking care when needed. Physical health is attained through exercise, eating well, getting enough sleep and paying attention to the signs of illness and getting help when needed.

I engage in vigorous exercise (examples include jogging, brisk walking, swimming, cycling)for 20–60 minutes at least four times per week. *

Almost, always

Sometimes

Never

I eat fruits, vegetables, and whole grains every day. *

Almost, always

Sometimes

Never

I avoid tobacco products. *

Almost, always

Sometimes

Never

vispār nesmēķēju

I wear a seat belt while riding in and driving a car. *

Almost, always

Sometimes

Never

I deliberately minimize my intake of cholesterol, dietary fats, and trans fats. *

Almost, always

Sometimes

Never

I avoid drinking alcoholic beverages or I consume no more than one (women) or two (men)drinks per day. *

Almost, always

Sometimes

Never

I get 7–9 hours of sleep most nights. *

Almost, always

Sometimes

Never

I have adequate coping mechanisms for dealing with stress. *

Almost, always

Sometimes

Never

I maintain a regular schedule of immunizations, physical and dental checkups (including Paptests, and blood pressure and cholesterol checks), and monthly self-exams of breasts/testicles. *

Almost, always

Sometimes

Never

I maintain a healthy weight, avoiding extremes of overweight and underweight. *

Almost, always

Sometimes

Never

Intellectual Dimension

Intellectual wellness involves having an open mind when you encounter new ideas and continuing to expand your knowledge. It encourages active participation in scholastic, cultural and community activities.

I seek opportunities to learn new things. *

Almost, always

Sometimes

Never

I try to keep abreast of current affairs—local, national, and international. *

Almost, always

Sometimes

Never

I enjoy attending special lectures, plays, musical performances, museums, galleries, and/or libraries. *

Almost, always

Sometimes

Never

I enjoy watching educational programs on TV. *

Almost, always

Sometimes

Never

I enjoy creative and stimulating mental activities/games. *

Almost, always

Sometimes

Never

I am happy with the amount and variety that I read. *

Almost, always

Sometimes

Never

I make an effort to improve my verbal, writing, and expression skills. *

Almost, always

Sometimes

Never

A continuing education program is/will be important to me in my career. *

Almost, always

Sometimes

Never

I am able to analyze, synthesize, and see more than one side of an issue. *

Almost, always

bieži

reti

I enjoy engaging in intellectual discussions. *

Almost, always

Sometimes

Never

Emotional Dimension

Emotional wellness relates to understanding your feelings and coping effectively with stress. It is important to pay attention to self-care, relaxation, stress reduction and the development of inner resources so you can learn and grow from experiences.

I am able to develop and maintain close relationships. *

Almost, always

Sometimes

Never

I accept responsibility for my actions. *

Almost, always

Sometimes

Never

I see challenges and change as opportunities for growth. *

Almost, always

Sometimes

Never

I feel I have considerable control over my life. *

Almost, always

Sometimes

Never

I am able to laugh at life and myself. *

Almost, always

Sometimes

Never

I am able to cope appropriately with stress and tension. *

Almost, always

Sometimes

Never

I am able to recognize my personal short comings and learn from my mistakes. *

Almost, always

Sometimes

Never

I am able to recognize and appropriately express my feelings. *

Almost, always

Sometimes

Never

I relax and enjoy life without the use of alcohol or drugs. *

Almost, always

Sometimes

Never

Social Dimension

Social wellness helps you perform social roles effectively and comfortably, and create a support network. This dimension of wellness allows you to not only develop encouraging relationships with peers, but also intimate relationships with romantic partners

I contribute time and/or money to social and community projects. *

Almost, always

Sometimes

Never

I am committed to a life time of volunteerism. *

Almost, always

Sometimes

Never

I exhibit fairness and justice in dealing with people. *

Almost, always

Sometimes

Never

I have a network of close friends and/or family. *

Almost, always

Sometimes

Never

I am interested in others, including those with backgrounds different from my own. *

Almost, always

Sometimes

Never

I am able to balance my needs with the needs of others. *

Almost, always

Sometimes

Never

I am able to communicate with and get along with a wide variety of people. *

Almost, always

Sometimes

Never

I obey the laws and rules of our society. *

Almost, always

Sometimes

Never

I am a compassionate person and try to help others when I can. *

Almost, always

Sometimes

Never

I support and help with family, neighborhood, school, and work social gatherings. *

Almost, always

Sometimes

Never

Spiritual Dimension

Spiritual wellness allows you to develop a set of values that help you seek meaning and purpose. Spirituality can be represented in many ways, for example, through relaxation or religion. But being spiritually well means knowing which resources to use to cope with issues that come up in everyday life.

I feel comfortable and at ease with my spiritual life. *

Almost, always

Sometimes

Never

There is a direct relationship between my personal values and my daily actions. *

Almost, always

Sometimes

Never

When I get depressed or frustrated by problems, my spiritual beliefs and values give me direction. *

Almost, always

Sometimes

Never

Prayer, meditation, and/or quiet personal reflection is/are important in my life. *

Almost, always

Sometimes

Never

Life is meaningful for me, and I feel a purpose in life. *

Almost, always

Sometimes

Never

I am able to speak comfortably about my personal values and beliefs. *

Almost, always

Sometimes

Never

I am consistently striving to grow spiritually, and I see that as a lifelong process. *

Almost, always

Sometimes

Never

I am tolerant of and try to learn about others’ beliefs and values. *

Almost, always

Sometimes

Never

I have a strong sense of hope and optimism in my life and use my thoughts and attitudes in life-affirming ways. *

Almost, always

Sometimes

Never

I appreciate the natural forces that exist in the universe. *

Almost, always

Sometimes

Never

Environmental Dimension

Environmental wellness inspires us to live a lifestyle that is respectful of our surroundings. This realm encourages us to live in harmony with the Earth by taking action to protect it. Environmental well-being promotes interaction with nature and your personal environment. Everyone can have a strong environmental conscious simply by raising their awareness.

I consciously conserve energy (electricity, heat, light, water, etc.) in my place of residenceand work. *

Almost, always

Sometimes

Never

I practice recycling (glass, paper, plastic, etc.). *

Almost, always

Sometimes

Never

I am committed to cleaning up the environment (air, soil, water, etc.). *

Almost, always

Sometimes

Never

I consciously carpool, ride a bicycle, walk, or use a gas-effi cient vehicle to conserve fuel energyand lessen the pollution in the atmosphere. *

Almost, always

Sometimes

Never

I limit the use of fertilizers and chemicals when managing my yard/lawn/outdoor living space. *

Almost, always

Sometimes

Never

I limit my use of aerosol sprays. *

Almost, always

Sometimes

Never

I do not litter. *

Almost, always

Sometimes

Never

I volunteer my time for environmental conservation projects. *

Almost, always

Sometimes

Never

I purchase recycled items when possible, even if they cost more. *

Almost, always

Sometimes

Never

I feel strongly about doing my part to preserve the environment. *

Almost, always

Sometimes

Never

Occupational Dimension

Occupational wellness is about enjoying your occupational endeavors and appreciating your contributions. This dimension of wellness encourages personal satisfaction and enrichment in one’s life through work.

I am happy with my career choice. *

Almost, always

Sometimes

Never

I look forward to working in my career area. *

Almost, always

Sometimes

Never

The job responsibilities/duties of my career choice are consistent with my values. *

Almost, always

Sometimes

Never

The payoffs/advantages in my career choice are consistent with my values. *

Almost, always

Sometimes

Never

I am happy with the balance between my work/career choice time commitment and leisure time. *

Almost, always

Sometimes

Never

I am happy with the amount of control I have in my work/career choice. *

Almost, always

Sometimes

Never

My work/career choice gives me personal satisfaction and stimulation. *

Almost, always

Sometimes

Never

I am happy with the professional/personal growth provided by my job/career choice. *

Almost, always

Sometimes

Never

I feel my job/career choice allows me to make a difference in the world. *

Almost, always

Sometimes

Never

My job/career choice contributes positively to my overall well-being. *

Almost, always

Sometimes

Never

Financial Wellness

Financial Wellness involves the process of learning how to successfully manage financial expenses. Money plays a critical role in our lives and not having enough of it impacts health as well as academic performance. Financial stress is repeatedly found to be a common source of stress, anxiety and fear for college students.

It is easy for me to balance my financial budget. *

Almost, always

Sometimes

Never

I believe it is more important to spend money than to earn it. *

Almost, always

Sometimes

Never

I am confident that I can plan my financial budget. *

Almost, always

Sometimes

Never

I repay loans on a monthly basis according to the payment schedule (if I have any) *

Almost, always

Sometimes

Never

I have enough money to avoid financial emergencies. *

Almost, always

Sometimes

Never

I follow up with my expenses to spend according to my budget. *

Almost, always

Sometimes

Never

I feel anxious about the amount of money I owe (credit cards, student loans, etc.) *

Almost, always

Sometimes

Never

I'm stressed about my finances. *

Almost, always

Sometimes

Never

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