Answer all questions and then hit the submit button at the bottom of this
1. I exercise aerobically (continuous, vigorous exercise producing
sweat for a minimum of thirty minutes) at least _____ per week.
2. My resting pulse rate is _____ beats per minute.
3. I avoid the extremes of too much or too little exercise.
4. I approach exercise in a relaxed manner.
5. I increase my exercise by walking or biking whenever possible.
6. I stretch before exercising.
7. I stretch after exercising.
8. I get an adequate amount of sleep.
9. My exercise program includes and adequate amount of each of the
three major fitness components--endurance, strength and flexibility.
10. If I am not in shape, I avoid sporadic (once a week or less)
1. When choosing non-vegetable protein, I select lean cuts of meat,
poultry, and fish.
2. I minimize my salt intake.
3. I eat fruits and vegetable fresh and uncooked.
4. I eat breakfast.
5. I include fiber in my diet on a daily basis.
6. I drink enough fluid to keep my urine light yellow.
7. I plan my diet to insure an adequate amount of vitamins and
8. I minimize foods in my diet that contain large amounts of refined
flour (bleached white flour, typical store bread, cakes, etc.)
9. I minimize my intake of fats and oils including margarine and
10. I avoid adding sugar to my food and I minimize my intake of
pre-sweetened food such as sugar-coated cereals, syrups, chocolate milk, and
most processed and fast foods
1. I maintain an up-to-date immunization record.
2. I examine my breasts or testes on a monthly basis.
3. I take action to minimize my exposure to tobacco smoke.
4. When I'm experiencing illness or injury, I take necessary steps to
correct the problem.
5. I brush my teeth after eating.
6. I floss my teeth after eating.
7. My resting pulse is 60 or less.
9. I keep my blood pressure in a range that minimizes my chances of
disease (e.g. stroke, heart attack kidney).
10. I keep my cholesterol level, high density lipids and triglycerides
in a range that minimizes my chances of disease.
1. I do not operate vehicles under the influence of alcohol or other
2. I do not ride with vehicle operators who are under the influence of
alcohol or other drugs.
3. I stay within the speed limit.
4. I maintain a safe driving distance between cars based on speed.
5. Vehicles which I drive are maintained to assure safety.
6. I avoid use of tobacco.
7. I do not consume more than two alcoholic drinks per day.
8. I avoid using drugs obtained from unlicensed sources.
9. I consider alternatives to drugs.
10. I follow the instructions provided with any drug I take.
1. I take steps to conserve energy in my place of residence.
2. I contribute to the feeling of acceptance within my family.
3. When I see a safety hazard, I take action (warn other or correct
4. I avoid unnecessary radiation.
5. I contribute time and/or money to community projects.
6. I use creativity in constructive ways.
7. My behavior reflects fairness and justice.
8. When possible, I choose an environment which is free of noise
9. When possible, I choose an environment which is free of air
10. I do my part to promote clean air.
1. I am comfortable in my relationships with others.
2. I feel positive about myself.
3. I feel there is an appropriate amount of excitement in my life.
4. My emotional life is stable.
5. When I make mistakes, I learn from them.
6. I feel enthusiastic about my life.
7. I find it easy to laugh.
8. I enjoy my life.
9. I have plenty of energy.
10. My sleep is restful.
1. I can express my feelings of anger.
2. I say 'NO' without feeling guilty.
3. I make decisions with a minimum of stress and worry.
4. There is an appropriate amount of time urgency in my daily routine.
5. I include relaxation time as part of my daily routine.
6. I am able to develop close, intimate relationships.
7. I set realistic objectives for myself.
8. I can relax my body and mind (without using drugs).
9. I accept responsibility for my actions.
10. I accept the responsibility for creating my own feelings.
1. I keep abreast of social and political issues.
2. I am interested in learning about scientific discoveries.
3. I make an effort to maintain and improve my verbal skills.
4. I make an effort to maintain and improve my writing skills.
5. I am satisfied with the entertainment choices I make.
6. I carefully select my movies and television choices.
7. I maintain a continuing education program relative to my career.
8. I am satisfied with the amount and variety I read.
9. It's easy for me to apply knowledge gained in one situation to a
10. I am interested in understanding the views of others.
1. I enjoy my work.
2. I take advantage of opportunities to learn new skills in my work.
3. My work is challenging.
4. I feel my job responsibilities are consistent with my values.
5. I look forward to doing my job.
6. I am satisfied with the balance between my work time and leisure.
7. I am satisfied with my ability to plan my workload.
8. I receive adequate feedback to judge my work performance.
9. To extent that I can, I create an environment which minimizes my
10. To the extent I can, I create an environment which minimizes the
stress at my organizational level or other levels.
1. I am satisfied with my spiritual life.
2. Prayer, meditation, and/or quiet personal time is/are important
part(s) of my life.
3. My values guide my daily life.
4. My spiritual growth is an important lifelong process.
5. I am concerned about humanitarian issues.
6. I participate in discussions about spiritual values.
7. Contemplating my purpose in life is an important issue for me.
8. I am satisfied with the degree to which my job is consistent with
9. I am satisfied with the degree to which my leisure time activities
support my life goals.
10. I am tolerant of the values and beliefs of others.