Health Promoting Lifestyle Survey

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Student ID *

Gender *

Female

Male

Choose a diet low in fat, saturated fat, and cholesterol. *

Never

Sometimes

Often

Routinely

Report any unusual signs or symptoms to a physician or other health professional *

Never

Sometimes

Often

Routinely

Follow a planned exercise program. *

Never

Sometimes

Often

Routinely

Get enough sleep. *

Never

Sometimes

Often

Routinely

Limit use of sugars and food containing sugar (sweets). *

Never

Sometimes

Often

Routinely

Read or browse internet about improving health. *

Never

Sometimes

Often

Routinely

Exercise vigorously for 20 or more minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber). *

Never

Sometimes

Often

Routinely

Take some time for relaxation each day. *

Never

Sometimes

Often

Routinely

Eat 6-11 servings of bread, cereal, rice and pasta each day. *

Never

Sometimes

Often

Routinely

Take part in light to moderate physical activity (such as sustained walking 30-40 minutes 5 or more times a week). *

Never

Sometimes

Often

Routinely

Eat 2-4 servings of fruit each day. *

Never

Sometimes

Often

Routinely

Take part in leisure-time (recreational) physical activities (such as swimming, dancing, bicycling). *

Never

Sometimes

Often

Routinely

Eat 3-5 servings of vegetables each day. *

Never

Sometimes

Often

Routinely

Do stretching exercises at least 3 times per week. *

Never

Sometimes

Often

Routinely

Work toward long-term goals in my life. *

Never

Sometimes

Often

Routinely

Eat 2-3 servings of milk, yogurt or cheese each day. *

Never

Sometimes

Often

Routinely

Get exercise during usual daily activities (such as walking during lunch, using stairs instead of elevators, parking car away from destination and walking) *

Never

Sometimes

Often

Routinely

Balance time between work and play. *

Never

Sometimes

Often

Routinely

Eat only 2-3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day. *

Never

Sometimes

Often

Routinely

Check my pulse rate when exercising. *

Never

Sometimes

Often

Routinely

Practice relaxation or meditation for 15-20 minutes daily. *

Never

Sometimes

Often

Routinely

Read labels to identify nutrients, fats, and sodium content in packaged food. *

Never

Sometimes

Often

Routinely

Attend educational programs on personal health care. *

Never

Sometimes

Often

Routinely

Reach my target heart rate when exercising. *

Never

Sometimes

Often

Routinely

Eat breakfast. *

Never

Sometimes

Often

Routinely

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