Instructions: Circle the appropriate number after each of the following statements and add up the numbers to get a total score for each section. Then check the norms at the end to determine what your score means.
Eating habits: Almost always Sometimes Almost never
1. I eat a variety of foods each day, such as fruits and vegetables, whole-grain breads and cereals, lean meats, dairy products, dry peas and beans, and nuts and seeds.
4 1 0
2. I limit the amount of fat, saturated fat, and cholesterol I eat (including fat in meats, eggs, butter, cream, shortenings, and organ meats such as liver).
2 1 0
3. I limit the amount of salt I eat by cooking with only small amounts, not adding salt at the table, and avoiding salty snacks.
2 1 0
4. I avoid eating too much sugar (especially frequent snacks of sticky candy or soft drinks).
2 1 0
Eating habits score: ___________
Exercise/fitness: Almost always Sometimes Almost never
1. I maintain a desired weight, avoiding overweight and underweight.
3 1 0
2. I do vigorous exercises for 15 to 30 minutes at least three times a week (examples include running, swimming, and brisk walking).
3 1 0
3. I do exercises that enhance my muscle tone for 15 to 30 minutes at least three times a week (examples include yoga and calisthenics).
2 1 0
4. I use part of my leisure time participating in individual, family, or team activities that increase my level of fitness (such as gardening, bowling, golf, and baseball).
2 1 0
Exercise/fitness score: ___________
Alcohol and drugs: Almost always Sometimes Almost never
1. I avoid drinking alcoholic beverages or I drink no more than one or two drinks a day.
4 1 0
2. I avoid using alcohol or other drugs (especially illegal drugs) as a way of handling stressful situations or the problems in my life.
2 1 0
3. I am careful not to drink alcohol when taking certain medicines (e.g., medicine for sleeping, pain, colds, and allergies).
2 1 0
4. I read and follow the label directions when using prescribed and over-the-counter drugs.
2 1 0
Alcohol and drugs score: ___________
What your scores mean:
9–10 Excellent 6–8 Good 3–5 Mediocre 0–2 Poor