A C T I V I T Y 1.

Wellness Lifestyle Questionnaire

Name: Date:

Course: Section: Gender: Age:

Nearly always
The purpose of this questionnaire is to analyze current lifestyle habits and help determine changes
necessary for future health and wellness. Check the appropriate answer to each question, and obtain

Seldom
Always

Never
Often
a final score according to the guidelines provided at the end of the questionnaire.

1. I participate in vigorous-intensity aerobic activity for 20 minutes on 3 or more days per week, 5 4 3
✔ 2 1
and I accumulate at least 30 minutes of moderate-intensity physical activity on a minimum of
2 additional days per week.
2. I participate in strength-training exercises, using a minimum of eight different exercises, 5 4 3 2
✔ 1
2 or more days per week.
3. I perform flexibility exercises a minimum of 2 days per week. 5 4
✔ 3 2 1
4. I maintain recommended body weight (includes avoidance of excessive body fat, excessive 5 4 3 2 1
✔
thinness, or frequent fluctuations in body weight).
5. Every day, I eat three regular meals that include a wide variety of foods. 5 4
✔ 3 2 1
6. I limit the amount of saturated fat and trans fats in my diet on most days of the week. 5
✔ 4 3 2 1
7. I eat a minimum of five servings of fruits and vegetables and six servings from grain products 5 4 3
✔ 2 1
daily.
8. I regularly avoid snacks, especially those that are high in calories and fat and low in nutrients 5 4
✔ 3 2 1
and fiber.
9. I avoid cigarettes or tobacco in any other form. 5 4 3 2 1
✔
10. I avoid alcoholic beverages. If I drink, I do so in moderation (one daily drink for women and two 5 4 3 2 1
for men), and I do not combine alcohol with other drugs.
11. I avoid addictive drugs and needles that have been used by others. 5 4 3 2 1
12. I use prescription drugs and over-the-counter drugs sparingly (only when needed), and I follow ✔
5 4 3 2 1
all directions for their proper use.
13. I readily recognize and act on it when I am under excessive tension and stress (distress). 5 4 3 2 1
14. I am able to perform effective stress-management techniques. 5 4 3 2 1
15. I have close friends and relatives with whom I can discuss personal problems and approach for 5 4 3 2 1
help when needed and with whom I can express my feelings freely.
16. I spend most of my daily leisure time in wholesome recreational activities. 5 4 3 2 1
17. I sleep 7 to 8 hours each night. 5 4 3 2 1
18. I floss my teeth every day and brush them at least twice daily. 5 4 3 2 1
19. I get “safe sun” exposure—that is, 10 to 20 minutes of unprotected exposure to the face, neck, 5 4 3 2 1
and arms on most days of the week between the hours of 10:00 a.m. and 4:00 p.m. I avoid
overexposure to the sun, and I use sunscreen and appropriate clothing when I am out in the sun
for an extended time.
20. I avoid using products that have not been shown by science to be safe and effective. (This 5 4 3 2 1
includes drugs and unproven nutrient and weight loss supplements.)
21. I stay current with the warning signs for heart attack, stroke, and cancer. 5 4 3 2 1
22. I practice monthly breast/testicle self-exams, get recommended screening tests (blood lipids, 5 4 3 2 1
blood pressure, Pap tests), and seek a medical evaluation when I am not well or when disease
symptoms arise.
23. I have a dental checkup at least once a year, and I get regular medical exams according to age 5 4 3 2 1
recommendations.
24. I am not sexually active. / I practice safe sex. 5 4 3 2 1
25. I can deal effectively with disappointments and temporary feelings of sadness, loneliness, and 5 4 3 2 1
depression. If I am unable to deal with these feelings, I seek professional help.
26. I can work out emotional problems without turning to alcohol, other drugs, or violent behavior. 5 4 3 2 1
32 Lifetime Physical Fitness and Wellness
Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
 A C T I V I T Y 1. 2

Wellness Lifestyle Questionnaire (continued)

Nearly always

Seldom
Always

Never
Often
27. I associate with people who have a positive attitude about life. 5 4 3 2 1
28. I respond to temporary setbacks by making the best of the circumstances and by 5 4 3 2 1
moving ahead with optimism and energy. I do not spend time and talent worrying about
failures.
29. I wear a seat belt whenever I am in a car, I ask others in my vehicle to do the same, and I 5 4 3 2 1
make sure that children are in an infant seat or wear a shoulder harness.
30. I do not drive under the influence of alcohol or other drugs, and I make an effort to keep 5 4 3 2 1
others from doing the same.
31. I avoid being alone in public places, especially after dark; I seek escorts when I visit or 5 4 3 2 1
exercise in unfamiliar places.
32. I seek to make my living quarters accident-free, and I keep doors and windows locked, 5 4 3 2 1
especially when I am home alone.
33. I try to minimize environmental pollutants, and I support community efforts to minimize 5 4 3 2 1
pollution.
34. I use energy conservation strategies and encourage others to do the same. 5 4 3 2 1
35. I study and/or work in a clean environment (including avoidance of secondhand smoke). 5 4 3 2 1
36. I participate in recycling programs for paper, cardboard, glass, plastic, and aluminum. 5 4 3 2 1
How to Score
Enter the score you have marked for each question in the spaces provided below. Next, total the score for each specific wellness lifestyle
category and obtain a rating for each category according to the criteria provided below.
Health- Avoiding Stress Personal Environmental
related chemical manage- hygiene/ Disease Emotional Personal health &
fitness Nutrition dependency ment health prevention well-being safety protection

1. 5. 9. 13. 17. 21. 25. 29. 33.

2. 6. 10. X 14. 18. 22. 26. 30. X 34.

3. 7. 11. X 15. 19. 23. 27. 31. 35.

4. 8. 12. 16. 20. 24. X 28. 32. 36.

Total:

Rating:

Category Rating
Excellent (E) 5 $17 Your answers show that you are aware of the importance of this category to your health and wellness. You are putting
your knowledge to work for you by practicing good habits. As long as you continue to do so, this category should not pose a health risk.
You are also setting a good example for family and friends to follow. Because you got a very high score on this part of the test, you
may want to consider other categories in which your score indicates room for improvement.
Good (G) 5 13–16 Your health practices in this area are good, but you have room for improvement. Look again at the items you
answered with a 4 or lower and identify changes that you can make to improve your lifestyle. Even small changes often can help you
achieve better health.
Needs Improvement (NI) 5 #12 Your health risks are showing. You may be taking serious and unnecessary risks with your health. Perhaps
you are not aware of the risks or what to do about them. Most likely you need additional information and help in deciding how to
successfully make the changes you desire. You can easily get the information that you need to improve, if you wish. The next step is up to you.
Please note that no final overall rating is provided for the entire questionnaire because it may not be indicative of your overall wellness.
For example, an excellent rating in most categories will not offset the immediate health risks and life-threatening consequences of using
addictive drugs or not wearing a seat belt.

Chapter 1 Physical Fitness and Wellness 33

Copyright 2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.