Test

How many days per week do you eat breakfast?

6 – 7

2 – 3

4 – 5

0 – 1

Which choice most closely describes your daily eating pattern?

eating snack foods (potato chips, soda pop, etc.) whenever

I am hungry

eating one balanced meal per day and eating snack foods

at other times during the day

eating two balanced meals a day and eating snack foods at

other times of the day

eating three balanced meals a day and eating snack foods

at other times of the day

eating three balanced meals per day and not snacking

How many days per week do you eat a balanced diet that includes the minimum number of servings from the four food groups as listed below? 2 servings of meat or protein substitutes

2 servings of dairy products

4 servings of breads and cereals

4 servings of fruits and vegetables

6 – 7

2 – 3

4 – 5

0 – 1

How many servings per day of concentrated sources of sugar (soda

pop, candy, cookies, etc.) do you eat?

0 or less than 1

3 – 4

1 – 2

5 or more

Considering you height and body build, how many pounds within your

Ideal weight do you fall?

within 10 pounds

within 20 pounds

within 30 pounds

more than 30 pounds from ideal

Which choice most closely describes you dieting behavior?

never being overweight, so never dieting

being more than 10 pounds overweight, but not dieting

when overweight, going on a fad diet to lose weight quick

when overweight, attempting to lose weight gradually (1 – 2

pounds per week) by increasing exercise or decreasing

food intake

when overweight, attempting to lose weight gradually (1 – 2

pounds per week) by increasing exercise and decreasing

food intake

What is the average number of hours per night that you sleep?

More then 10

5 – 6

9 – 10

0 – 4

7 – 8

How often do you use seatbelts while driving or riding in a car?

always

never in town and always on the highway

sometimes in town and sometimes on the highway

never

How often do you drive or ride with someone under the influences of

alcohol or drugs?

more than once per week

once per week

a few times per year

never

Which choice best describes your consumption of alcoholic

beverages?

not drinking

drinking one drink or less per day

drinking two drinks or less per day

drinking two or less on weekdays, more than two drinks

per day on weekends

drinking more than two drinks per day on most days

Which choice best describes your drug use patterns (over the counter

prescriptions, and recreational drugs)?

using the drugs I want whenever I want.

using the drugs I fell I need while following common sense

using only medically required drugs exactly as directed

rarely using drugs of any kind

How many cups of caffeinated beverages (coffee, tea, cola, etc.) do

you drink per day?

none or less than 1

4 – 6

1 – 3

7 or more

Which choice best describes your cigarette smoking behavior?

not smoking

smoking less than one pack per day

smoking 1 – 2 packs per day

smoking more than 2 pack per day

How many times per week do you exercise aerobically (biking,

jogging, swimming, aerobics, etc.)?

less than 1

3 - 4

1

5 or more

2

How many times per week do you do other types of exercise (weight

lifting, tennis, calisthenics, racquetball, basketball, etc.) besides

aerobic activities?

less than 1

3 – 4

1

5 or more

2

How often do you brush your teeth?

after every meal

twice per day

once per day

less than once per day

How often do you have a dental check-up?

never or only when something is wrong

every 2 – 3 years

every year

every six months

How often do you have a medical check-up?

never or only when something is wrong

only for pap tests or other checks

every 3 – 5 years

at least every 2 years

How often do you read the labels of foods and over-the-counter drugs

before purchasing them?

always

sometimes

usually

rarely

How many times per week do you make a conscientious effort to

manage your stress by utilizing progressive relaxation, exercise, religion,

music, or other stress-reduction techniques?

6 – 7

2 – 3

4 – 5

0 – 1

Which choice most correctly describes your closest interpersonal

relationship?

not having a friend

having a friend, but I am not able to share my real feelings with

the person

having a friendship where I can sometimes share my real

feelings, but sometimes can’t

having a friendship where I can always share my real feelings

How many servings per day of foods high in saturated fats or

cholesterol (whole milk, eggs, sausage, bacon, red meat, etc.) do you eat?

0

3 – 4

1 – 2

5 or more

How often do you limit your consumption of salt by doing things like not salting your food at the table, using salt sparingly when preparing foods,

and limiting your intake of salty foods?

always

sometimes

usually

rarely

How often do you practice breast-examination (female) or testicular

self-examination (male)?

every month

every 2 – 6 months

less frequently than every 6 months

never

Which choice best describes your contraceptive use?

Not sexually active, so don’t use contraceptives

attempting to get pregnant or am pregnant, so don’t use

contraceptives

sexually active and always use contraceptives

sexually active and usually use contraceptives

sexually active and sometimes use contraceptives

sexually active and rarely use contraceptives