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Healthy Living Lifestyle Assessment Questionnaire

This form asks you a variety of questions about your lifestyle habits, and takes about 3 minutes to
complete. Please fill in the information requested, or place a check in the appropriate space. We thank
you for your time and effort in completing this questionnaire.

Personal Information

Todays Date:(mm/dd/yyyy)
Height:(without shoes)
What is the most you have ever weighed?:

Are you NOW trying to:
Lose weight
Gain weight
Stay about the same
Not trying to do anyhting

Medical History


Has your father or brother had a heart attack or died suddenly of heart disease before age 55
years; has your mother or sister experienced these heart problems before age 65 years?


Has a doctor told you that you have high blood pressure (more than 140/90 mm Hg), or are you on medication to control your blood pressure?


If you know your blood pressure please check the appropriate category:

Less than 120/80 mm Hg 140/90 to 159/99 Do Not Know
120/80 to 129/84 >160/100 to 180/110
130/85 to 139/89 More than 180/110


Is your total blood cholesterol greater than 240 mg/dl, or has a doctor told you that your
cholesteral is at a high risk level?


If you know your blood cholesterol, please check the appropriate category:

Less than 160 mg/dl 200-219 More than 260
160-179 200-219 Do not know
180-199 220-260


Do you have diabetes?


During the past year, would you say that you experienced enough stress, strain, and pressure
to have a significant effect on your health

Health and Nutrition

In general, compared to other persons your age, rate how healthy you are:
1 2 3 4 5 6 7 8 9 10
1 Being Not healthy at all; 10 being Extremely healthy

Outside of you normal work or daily responsibilities, how often do you engage in exercise that at least
moderatly increases your breathing and heart rate, and makes you sweat, for atleast 20 minutes (such
as brisk walking, cycling, swimming, jogging, aerobic dance, stair climbing, rowing, basketball, racquetball,
vigorous yard work, etc.)

5 or more times per week 3 to 4 times per week 1 to 2 times per week
Less than 1 time per week Seldom or never


Do you eat foods nearly every day that are high in fat and cholesterol such as fatty meats, cheese, fried foods, butter, whole milk, ice cream, or eggs?

On average, how many servings of fruit and vegetables do you eat per day? (One serving=1 medium
fruit, 1/2 cup of chopped, cooked, or canned fruit/vegetables, 3.4 cup of fruit or vegetable juice).
None 1-2 3-4 5-6 7-8 9 or more

On average, how many servings of bread, cereal, rice, or pasta do you eat per day? ( One serving=1
slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked cereal, rice, or pasta).
None 1-2 3-5 6-8 9-11 12 or more

Lifestyle Habits

How have you been feeling in general during the past month?

In excellent spirits In good spirits mostly In low spirits mostly
In very good spirits I've been up & down in spirits a lot In very low spirits

On average, how many hours of sleep do you get in a 24 hr period?
Less than 5 5 to 6.9 7 to 9 More than 9

How would you discribe your smoking habits?
Never smoked
Used to smoke

How many years has it been since you smoked?
Less than 1 year 6-15
1-5 More than 15

Still smoke

How many cigarettes a day do you smoke on average?
1-10 21-30 More than 40
11-20 31-40

How many alcoholic drinks do you consume? (A "drink" is a glass of wine, a wine cooler, a bottle/can of
beer, a shot glass of liquor, or a mixed drink).

Never use alcohol Less than 1 per week 1 to 6 per week
1 per day 2 to 3 per day More than 3 per day

When driving or riding in a car, do you wear a seat belt:
All or most of the time Some of the time Once in a while Rarely or never