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lifestyle questionnaire
how healthy are you?
Maybe you need to lose weight, but you’re pretty good about balancing the demands
of your daily life. Or maybe you already eat healthfully but can’t seem to find the
motivation to exercise. Taking the Lifestyle Questionnaire will give you insight into how
healthy your lifestyle is already—and what areas you can improve upon.
As you answer, be honest with yourself. Don’t select the answer that you’d like to say
is true; choose the one that best fits your lifestyle now. Regardless of whether you score
on the low side—or do better than you thought—you’ll have a snapshot of your current
habits to compare your progress to in the future.
1. Do you agree with the following statement? “I’m usually aware of what and how much I’m eating.”
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. Yes—I try to pay attention to my food because I enjoy it more.
. It depends on how busy I am and whether I’m eating solo or with others.
. No—in fact, I often eat at my desk, in the car, or while watching television.
2. How often do you feel “stuffed” or overly full after eating?
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a. Rarely.
b. Occasionally.
c. Quite often
3. How often do you skip meals? (And coffee doesn’t count as breakfast.)
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a. Rarely
b. Sometimes—it depends on my schedule or if I’m not hungry.
c. Frequently—I don’t eat breakfast, and lunch is often on the run.
4. How may 8-ounce glasses of water do you consume on an average day?
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a. Five glasses or more.
b. Two to five glasses.
c. Less than two glasses.
5. How often do you snack on chips or other junk food? (Be honest.)
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a. Rarely—and I pay attention to my portions
b. A few times a week.
c. Frequently—I need my salt or sugar dose every day.
6. What type of protein do you usually consume?
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a. Fish, beans, skinless chicken breast, extra-lean beef, or pork
b. Chicken with the skin, or trimmed beef or pork.
c. Hamburgers, hot dogs, sausages, or marbled steaks.
7. Your diet includes beans, nuts, and soy products:
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a. Frequently and often.
b. Occasionally
c. Rarely.
8. How many servings of fruits and vegetables do you eat?
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a. Five or more servings a day.
b. Three or four servings a day
c. Less than two servings a day . . . and that’s counting french fries.
9. How many servings of dairy or other high-calcium foods do you consume every day?
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a. Three or more.
b. One or two.
c. Less than one a day.
10. You incorporate whole grains into your diet:
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a. Whenever possible.
b. Occasionally—you ask for whole wheat bread instead of white, for example.
c. Rarely
fitness check
11. How long can you walk fast without getting out of breath?
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a. Easily 30 minutes or more.
b. For 5 to 10 minutes.
c. Less than 5 minutes
12. Think back to high school. How does your current weight compare with your weight then?
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a. It’s about the same.
b. It’s gone up between 10 and 20 pounds.
c. It’s gone up 20 pounds or more.
13. How often do you exercise for at least 20 minutes at a stretch?
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a. I exercise three to five days a week, often vigorously
b. I exercise two or three days a week, but I rarely break a sweat.
c. I don’t exercise much at all
14. How often do you stretch?
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a. At least three times a week.
b. Once a week, when I think of it, or when I know it would feel good.
c. Never
15. How often do you strength-train or lift weights?
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a. Two or three times a week.
b. Rarely—I don’t want to bulk up.
b. Rarely—I don’t want to bulk up.
16. When was the last time you had fun during exercise?
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a. Within the last couple of days—I enjoy my usual routine.
b. Recently, playing ball with friends or chasing my kids.
c. I can’t remember the last time I had fun exercising; it always feels like a chore to me.
17. When was the last time you tried a new physical activity, whether alone or with someone else?
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a. In the last month.
b. In the last six months.
c. I can’t remember
18. Your spouse or friend has suggested a hiking trip this weekend. Your reaction?
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a. Great! It will be a chance to spend some fun time together
b. But I have so much to do—I can’t afford the time.
c. No way!
19. How often do you perform some form of sustained physical activity (like walking, gardening, or doing housework) for at least 20 minutes?
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a. Five times a week or more.
b. Three or four times a week.
c. Rarely.
20. How satisfied are you with the overall state of your physical body?
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a. Pretty satisfied.
b. I’d like to lose some weight and/or tone up.
c. I’d like to lose a lot of weight and completely reshape my body
wellness check
21. How easy is it for you to relax at the end of the day?
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a. It depends on the day. It is easy on most days
b. It’s difficult on many days.
c. It’s impossible. I couldn’t relax even if I had the time.
22. How often do you eat to comfort yourself or relieve stress?
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a. Rarely.
b. Sometimes.
c. Often.
23. How often do you feel like you’re living the life you want to?
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a. Frequently.
b. Occasionally.
c. Almost never.
24. You’d describe your desk at work or home as:
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a. Fairly organized.
b. Pretty disorganized, but I know where the important piles are.
c. A complete mess.
25. Which answer best describes how you use your cell phone or smartphone (whether texting, e-mailing, or making/taking calls)?
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a. I use it for necessary communication and socializing but can easily turn it off when I want to.
b. I often feel chained to it, but I am comfortable shutting it off for some downtime.
c. I feel it has taken over my life and can’t seem to put it down, even at dinner or on vacation.
26. How would you describe your sleep habits?
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a. I usually feel rested when I wake up
b. I could use extra sleep most mornings.
c. I need a forklift to get out of bed.
27. How often do you feel emotionally out of control?
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a. Rarely, unless I’m under extreme stress
b. Occasionally
c. Frequently.
28. How often do you take time to do something just for you?
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a. Every day.
b. Occasionally.
c. Are you kidding? I have a job and a family—I don’t have time just for me!
29. How many close friends would you say you have?
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a. Several.
b. One, but I can talk to him/her about anything.
c. I’m not that close to anyone.
30. When you think about the future, how do you feel?
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a. Excited—I have lots to look forward to.
b. Worried that I’ll never catch up on everything I have to do.
c. I try not to think about the future—it’s too overwhelming.
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