A Ten-Thousand Foot View
Commitment
What is your present level of commitment to addressing any changes needed that relate to
your lifestyle? Rate from 0 to 10, 10 being fully committed.
0 1 2 3 4 5 6 7 8 9 10
Strength
What behaviours of lifestyle habits do you currently engage in regularly that you believe
support your health?
______________________________________________________________________________
___________________________________________________________________
What behaviours or lifestyle habits do you currently engage in regularly that you believe are
self-destructive?
______________________________________________________________________________
___________________________________________________________________
Support
Who do you know that will sincerely and consistently support you with the beneficial lifestyle
changes that you will be making?
______________________________________________________________________________
___________________________________________________________________
Manage
What is your present level of stress (psychological, physical, workplace)?
Rate from 0 to 10, 10 being totally stressed out.
0 1 2 3 4 5 6 7 8 9 10
What do you love to do?
______________________________________________________________________________
___________________________________________________________________
Wellness Self-Assessment
How often have you been physically activity this week (30-minute intervals of moderate
[walking] to intense activity)?
0 1 2 3 4 5 6 7 8 9 10
How many 237 mL (8 oz – 1 cup) glasses of water did you drink yesterday?
0 1-3 4-7 8-10
How many servings of fruits/vegetables did you have yesterday 125 mL (1/2 cup)?
0 1-3 4-7 8-10
How many servings of traditional foods have you had this past week? Consider foods from your
own cultural background.
0 | 1-3 | 4-7 | 8-10 |
Do you need to quit smoking? | Yes | No |
Health, Wellness & Quality of Life Questionnaire Answer each of the questions below
by putting a circle around the number that best represents you currently.
Resarader, 2020
Physical State rate the following with respect to frequency:
Never | Rarely | Occasionally | Regularly | Constantly | |
1. Presence of physical pain (neck/back ache, sore arms/legs, etc.) |
1 | 2 | 3 | 4 | 5 |
2. Feeling of tension or stiffness or lack of flexibility in your spine |
1 | 2 | 3 | 4 | 5 |
3. Incidence of fatigue or low energy |
1 | 2 | 3 | 4 | 5 |
4. Incidence of colds and flu | 1 | 2 | 3 | 4 | 5 |
5. Incidence of headaches (of any kind) |
1 | 2 | 3 | 4 | 5 |
6. Incidence of nausea or constipation |
1 | 2 | 3 | 4 | 5 |
7. Incidence of menstrual discomfort |
1 | 2 | 3 | 4 | 5 |
8. Incidence of allergies or skin rashes |
1 | 2 | 3 | 4 | 5 |
9. Incidence of dizziness or light headedness |
1 | 2 | 3 | 4 | 5 |
10. Incidence of accident or near accidents, or falling and tripping |
1 | 2 | 3 | 4 | 5 |
Mental and Emotional State rate the following questions with respect to frequency:
Never | Rarely | Occasionally | Regularly | Constantly | |
1. If pain is present, how distressed are you about it? |
1 | 2 | 3 | 4 | 5 |
2. Presence of negative or critical feelings about yourself |
1 | 2 | 3 | 4 | 5 |
3. Experience of moodiness or temper or angry outbursts |
1 | 2 | 3 | 4 | 5 |
4. Experience of depression or lack of interest |
1 | 2 | 3 | 4 | 5 |
5. Being overly worried about small things |
1 | 2 | 3 | 4 | 5 |
6. Difficulty thinking or concentrating or indecisiveness |
1 | 2 | 3 | 4 | 5 |
Health, Wellness & Quality of Life Questionnaire Answer each of the questions below
by putting a circle around the number that best represents you currently.
Resarader, 2020
7. Experience of vague fears or anxiety |
1 | 2 | 3 | 4 | 5 |
8. Being fidgety or restless; difficulty sitting still |
1 | 2 | 3 | 4 | 5 |
9. Difficulty staying or falling asleep |
1 | 2 | 3 | 4 | 5 |
10. Experience of recurring thoughts or dreams |
1 | 2 | 3 | 4 | 5 |
Stress Evaluation evaluate your stress relative to the following:
Never | Rarely | Occasionally | Regularly | Constantly | |
1. Family | 1 | 2 | 3 | 4 | 5 |
2. Significant relationship | 1 | 2 | 3 | 4 | 5 |
3. Health | 1 | 2 | 3 | 4 | 5 |
4. Finances | 1 | 2 | 3 | 4 | 5 |
5. Sex life | 1 | 2 | 3 | 4 | 5 |
6. Work | 1 | 2 | 3 | 4 | 5 |
7. School | 1 | 2 | 3 | 4 | 5 |
8. General well-being | 1 | 2 | 3 | 4 | 5 |
9. Emotional well-being | 1 | 2 | 3 | 4 | 5 |
10. Coping with daily problems | 1 | 2 | 3 | 4 | 5 |
Life Enjoyment
Never | Rarely | Occasionally | Regularly | Constantly | |
1. Openness to guidance to your “inner voice/feeling” |
1 | 2 | 3 | 4 | 5 |
2. Experience of relaxation or ease or well-being |
1 | 2 | 3 | 4 | 5 |
3. Presence of positive feelings about yourself |
1 | 2 | 3 | 4 | 5 |
4. Interest in maintaining a healthy lifestyle (e.g. diet, fitness, etc.) |
1 | 2 | 3 | 4 | 5 |
5. Feeling of being open and aware/connected when relating to others |
1 | 2 | 3 | 4 | 5 |
6. Level of confidence in your ability to deal with adversity |
1 | 2 | 3 | 4 | 5 |
7. Level of compassion for, acceptance of, others |
1 | 2 | 3 | 4 | 5 |
8. Satisfaction with the level of recreation in your life |
1 | 2 | 3 | 4 | 5 |
Health, Wellness & Quality of Life Questionnaire Answer each of the questions below
by putting a circle around the number that best represents you currently.
Resarader, 2020
9. Incidence of feeling of joy or happiness |
1 | 2 | 3 | 4 | 5 |
10. Level of satisfaction with your sex life |
1 | 2 | 3 | 4 | 5 |
11. Time devoted to things you enjoy |
1 | 2 | 3 | 4 | 5 |
Overall Quality of Life
Never | Rarely | Occasionally | Regularly | Constantly | |
1. Your personal life | 1 | 2 | 3 | 4 | 5 |
2. Your wife/husband or “significant other” |
1 | 2 | 3 | 4 | 5 |
3. Your romantic life | 1 | 2 | 3 | 4 | 5 |
4. Your job | 1 | 2 | 3 | 4 | 5 |
5. Your co-workers | 1 | 2 | 3 | 4 | 5 |
6. The actual work you do | 1 | 2 | 3 | 4 | 5 |
7. The handling of problems in your life |
1 | 2 | 3 | 4 | 5 |
8. What you are accomplishing in your life |
1 | 2 | 3 | 4 | 5 |
9. Your physical appearance – the way you look to others |
1 | 2 | 3 | 4 | 5 |
10. Your self | 1 | 2 | 3 | 4 | 5 |
11. Your ability to adjust to change in your life |
1 | 2 | 3 | 4 | 5 |
12. Your life as a whole | 1 | 2 | 3 | 4 | 5 |
13. Overall contentment with your life |
1 | 2 | 3 | 4 | 5 |
14. The extent to which your life has been as you want it |
1 | 2 | 3 | 4 | 5 |
Overall Impressions
Better | Some | Worse | |
1. Overall, my physical well being is: |
1 | 2 | 3 |
2. Overall, my mental/emotional state is: |
1 | 2 | 3 |
3. Overall, my ability to handle stress is: |
1 | 2 | 3 |
4. Overall, my enjoyment of life is: |
1 | 2 | 3 |
5. Overall, my quality of life is: | 1 | 2 | 3 |
Assessing Your Self-Efficacy, Social-Support, and Self-Esteem
Tsai et al., 2014
Using a five-point rating scale (see below), identify how much you agree or disagree with the
eight statements below:
1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree
Questions:
1. I will be able to achieve most of the goals that I have set for myself ___
2. When facing difficult tasks, I am certain I will accomplish them ___
3. In general, I think that I can obtain outcomes that are important to me ___
4. I believe I can succeed at almost any endeavor to which I set my mind ___
5. I will be able to successfully overcome many challenges ___
6. I am confident that I can perform effectively on many different tasks ___
7. Compared to other people, I can do most tasks very well ___
8. Even when things are tough, I can perform quite well The higher the score, the higher the self-efficacy |
___ |
Self-Esteem Baumeister et al., 2003
Below is a list of statements dealing with your general feelings about yourself. Please indicate
how strongly you agree or disagree with each statement.
1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree
1. On the whole, I am satisfied with myself ___
2. At times I think I am no good at all ___
3. I feel that I have a number of good qualities ___
4. I am able to do things as well as most other people ___
5. I feel I do not have much to be proud of ___
6. I certainly feel useless at times ___
7. I feel that I’m a person of worth, at least on an equal plane with others ___
8. I wish I could have more respect for myself ___
9. All in all, I am inclined to feel that I am a failure ___
10. I take a positive attitude towards myself. Scoring: |
___ |
Items 2, 5, 6, 8, 9 are reversed. Give “strongly disagree” 1 point, “disagree” 2 points, “agree” 3
points, and “strongly agree” 4 points. Sum scores for all ten items. Keep scores on a continuous
scale. Higher scores indicate higher self-esteem.
Social Support Minnebo, 2005
This scale is made up of a list of statements each of which may or may not be true about you.
For each statement circle “definitely true” if you are sure it is true about you and “probably
true” if you think it is true but are not absolutely certain. Similarly, you should circle “definitely
false” if you are sure the statement is false and “probably false” if you think it is false but are
not absolutely certain.
1. If I wanted to go on a trip for a day (for example, to the mountains), I would have a hard
time finding someone to go with me.
definitely false | probably false | probably true | definitely true |
2. I feel that there is no one I can share my most private worries and fears with. | |||
definitely false | probably false | probably true | definitely true |
3. If I were sick, I could easily find someone to come help me with my daily chores.
definitely false probably false probably true definitely true
4. There is someone I can turn to for advice about handling problems with my family.
definitely false probably false probably true definitely true
5. If I decide one afternoon that I would like to go to a movie that evening, I could easily
find someone to go with me.
definitely false | probably false | probably true | definitely true |
6. When I need suggestions on how to deal with a personal problem, I know someone I can | |||
turn to. definitely false |
probably true | definitely true | |
probably false |
7. I don’t often get invited to do things with others.
definitely false | probably false | probably true | definitely true |
8. If I had to go out of town for a few weeks, it would be difficult to find someone who would look after my house or apartment (the plans, pets, garden, etc.) |
|||
definitely false | probably false | probably true | definitely true |
9. If I wanted to have lunch with someone, I could easily find someone to join me.
definitely false | probably false | probably true | definitely true |
10. If I was stranded 10 miles from home, there is someone I could call who could come and | |||
get me. definitely false |
probably true | definitely true | |
probably false |
11. If a family crisis arose, it would be difficult to find someone who could give me good
advice about how to handle it.
definitely false | probably false | probably true | definitely true |
12. If I needed some help in moving to a house or new apartment, I would have a hard time | |||
finding someone to help me. | |||
definitely false | probably false | probably true | definitely true |
Scoring:
Items 1, 2, 7, 8, 11, 12 are reverse scored.
Items 2, 4, 6, 11 make up the Appraisal support subscale.
Items 1, 5, 7, 9 make up the Belonging support subscale.
Items 3, 8, 10, 12 make up the Tangible support subscale.
Satisfaction with Life Scale Pavot & Diener, 1993
How Happy are You?
Read the following statements and then rate your level of agreement with each one
using the 1-7 scale.
1 = strongly disagree; 2 = disagree; 3 = slightly disagree; 4 = neither agree nor disagree;
5 = slightly agree; 6 = agree; 7 = strongly agree
1. In most ways, my life is close to my ideal ___
2. The conditions of my life are excellent ___
3. I am satisfied with my life ___
4. So far I have gotten the important things I want in life ___
5. If I could live my life over, I would change almost nothing | ___ |
Scoring: 31-35: you are very satisfied with your life 21-25: slightly satisfied 15-19: slightly dissatisfied 5-9: very dissatisfied |
|
26-30: satisfied 20: neither satisfied/dissatisfied 10-14: dissatisfied |
Recognizing Depression
Depression comes in different forms, just like other illnesses such as heart disease. Not
everyone with a depressive disorder experiences every symptom. The number and severity of
symptoms may vary among individuals and over time.
Read through the list and check any that apply to you.
– I am often restless and irritable
– I am having irregular sleep patterns – either too much or not enough
– I don’t enjoy hobbies, my friends, family or leisure activities any more
– I am having trouble managing my diabetes, hypertension, or other chronic illness
– I have nagging aches and pains that do not get better no matter what I do
– Specifically, I often experience:
o Digestive problems
o Headache or backache
o Vague aches and pains like joint or muscle pains
o Chest pains
o Dizziness
– I have trouble concentrating or making simple decisions
– Other have commented on my mood or attitude lately
– My weight has changed a considerable amount
– I have had several of the symptoms I checked above for more than two weeks
– I feel that my functioning in my everyday life (work, family, friends) is suffering because
of these problems
– I have a family history of depression
– I have thought about suicide
Answers.
Checking several items on this list does not necessarily mean that you have a depressive
disorder because many conditions can have similar symptoms. However, if you have checked
several items on this list, a conversation with your healthcare provider or therapist may be
helpful. Even though it can be difficult to talk about certain things, your healthcare provider is
knowledgeable, trained, and committed to helping you.
If you can’ t think of what to say, try these conversation-starters:
– “I just don’t feel like myself lately”
– “My friend/parent/roommate/spouse thinks I might be depressed”
– “I haven’t been sleeping well lately”
– “Everything seems harder than before”
– “Nothing’s fun anymore”
If you are diagnosed with depression, remember it is a common and highly treatable illness
with medical causes. Your habits or personality did not cause your depression and you don’t
have to face it alone.
Student Stress Scale
The Student Stress Scale, an adaptation of Holmes and Rahe’s Life Events Scale for college-age adults,
provides a rough indication of stress levels and possible health consequences.
In the Student Stress Scale, each event, such as beginning or ending school, is given a score that represents
the amount of readjustment a person must make because of the change. In some studies, using similar
scales, people with serious illnesses have been found to have high scores.
To determine your stress score, add up the number of points corresponding to the events you have
experienced in the past 12 months.
1. Death of a close family member 100
2. Death of a close friend 73
3. Divorce of parents 65
4. Jail term 63
5. Major personal illness or injury 63
6. Marriage 50
7. Getting fired from a job 47
8. Failing an important course 45
9. Change in the health of a family member 45
10. Pregnancy 44
11. Sex problems 40
12. Serious argument with a close friend 39
13. Change in academic major 39
14. Trouble with parents 39
15. New girlfriend/boyfriend/partner 37
16. Increase in workload at school 37
17. Outstanding personal achievement 36
18. First quarter/semester at college 36
19. Change in living conditions 31
20. Serious argument with an instructor 30
21. Getting lower grades than expected 29
22. Change in sleeping habits 29
23. Change in social activities 29
24. Change in eating habits 28
25. Chronic car trouble 26
26. Change in number of family get-togethers 26
27. Too many missed classes 25
28. Changing colleges or universities 24
29. Dropping more than one class 23
30. Minor traffic violations 20
Here’s how to interpret your score: If your score is 300 or higher, you’re at high risk for developing a health
problem. If your score is between 150 and 300 you have a 50-50 change of experiencing a serious health
change within two years. If your score is below 150, you have a one in three chance of a serious health change.
It is important to remember that different people deal with stress in different ways and that stressful situations are
a part of everyone’s lives at times.
Below, list three positive coping mechanisms that you believe could be valuable in promoting
positive health changes and when you would consider using them.
1.
2.
3.
Are you Sleeping Well? | Donatelle et al., 2019 |
Read each statement below, then select “True” or “False” according to whether it applies to | |
you in. your current school term. 1. I sometimes doze off in my morning classes |
T/F |
2. I sometimes doze off in my last class of the day T/F
3. I go through the day feeling tired T/F
4. I feel drowsy when I am a passenger in a bus or car T/F
5. I often fall asleep while reading or studying T/F
6. I often fall asleep at the computer or watching TV T/F
7. It usually takes me a long time to fall asleep T/F
8. My roommate (or partner) tells me I snore T/F
9. I wake up frequently throughout the night T/F
10. I have fall asleep while driving Scoring: |
T/F |
If you answered True more than once, you may be sleep deprived. Try the strategies in this
section and those that follow for getting more or better-quality sleep, and if you still experience
sleepiness, see your healthcare provider.
– Evaluate your behaviours and identify things you are doing that get in the way of a good
nights’ sleep. Develop a plan. What can you do differently starting today?
– Write a list of personal Dos and Don’ts. For instance: do turn off your cellphone after
11pm. Do not drink anything with caffeine after 5pm.
– Keep a sleep diary. Note not only how many hours you are sleeping each night, but also
how you feel and how you function the next day.
– Arrange your room to promote restful sleep. Remember the “cave”. Keep it quiet, cool,
and dark.
– Visit your campus healthcare centre and ask for more information about getting a good
night’s sleep.
– Establish a regular sleep schedule. Get in the habit of going to bed and waking at the
same time, even on weekends.
– Create a ritual, such as stretching, meditation, reading something light, or listening to
music, that you follow each night to help your body ease from the activity of the day
into restful sleep.
– If you are still having difficulty sleeping and you feel you might have a sleep disorder or
an underlying health problem disrupting your sleep, contact your healthcare provider.
FOSQ_10 SLEEP ASSESSMENT Weaver, 1996
Instructions
Some people have difficulty performing everyday activities when they feel tired or sleepy. The
purpose of this questionnaire is to find out if you generally have difficulty carrying out certain
activities because you are too sleepy or tired.
In this questionnaire, when the words “sleepy” or “tired” are used, it means the feeling that you
can’t keep your eyes open, your head is droopy, that you want to “nod off”, or that you feel the
urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after
you have exercised.
Directions
Please put a “check” in the box for your answer to each question. Select only one answer for
each question. Please try to be as accurate as possible.
Yes, extreme |
Yes, moderate |
Yes, a little |
No |
Do you have difficulty concentrating on the things you do because you are sleepy or tired? |
|||
Do you generally have difficulty remembering things because you are sleepy or tired? |
|||
Do you have difficulty finishing a meal because you become sleepy or tired? |
|||
Do you have difficulty working on a hobby (for example sewing, gardening, collecting) because you are sleepy or tired? |
|||
Do you have difficulty doing work around the house (for example, cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired? |
|||
Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you are sleepy or tired? |
|||
Do you have difficulty getting things done because you are too sleepy or tried to drive or take public transportation? |
|||
Do you have difficulty taking care of financial affairs and doing paperwork (for example, writing cheques, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired? |
|||
Do you have difficulty performing employed or volunteer work because you are sleepy or tired? |
Score: _____
C A N A D I A N S O C I E T Y F O R E X E R C I S E P H Y S I O L O G Y C S E P. C A
Please answer the following questions based on what you do in a typical week. To increase accuracy, you may
wish to log your physical activity and sedentary behavior for one week prior to answering the questions.
Aerobic Physical Activity
1. Frequency: In a typical week, how many days do you do moderate-intensity (like brisk walking) to vigorousintensity (like running) aerobic physical activity ?
days/week
2. Time or Duration: On average for days that you do at least moderate-intensity aerobic physical activity (as
specified above), how many minutes do you do?
minutes/day
Total: Multiply your average number of days per week by the average number of minutes per day.
minutes/week
Muscle Strengthening Physical Activity
3. In a typical week, how many times do you do muscle strengthening activities (such as resistance training or
very heavy gardening)?
times/week
Perceived Aerobic Fitness
4. In general, would you say that your aerobic fitness (ability to walk/run distances) is:
C S E P – PAT H : P H Y S I C A L A C T I V I T Y A N D S E D E N TA RY
B E H AV I O U R Q U E S T I O N N A I R E ( PA S B – Q )
A D U LT ( 1 8 A N D O V E R )
Excellent Very Good Good Fair Poor
TOOL #8
Reproduced With Permission
C A N A D I A N S O C I E T Y F O R E X E R C I S E P H Y S I O L O G Y C S E P. C A
Sedentary Behaviour
5. On a typical day, how many hours do you spend in continuous sitting: at work, in meetings, volunteer
commitments and commuting (i.e., by motorized transport)?
None
3 to < 4
None
3 to < 4
1 to < 2
5 to < 6
1 to < 2
5 to < 6
< 1 hour
4 to < 5
< 1 hour
4 to < 5
2 to < 3
> 6
2 to < 3
> 6
6. On a typical day, how many hours do you watch television, use a computer, read, and spend sitting quietly
during your leisure time?
Total Sedentary Behaviour (add responses to questions 5 and 6) hours/day
7. When sitting for prolonged periods (one hour or more), at what interval would you typically take a break to
stand and move around for two minutes?
< 10 minutes
10 to < 20 minutes
20 to < 30 minutes
30 to < 45 minutes
45 to < 1 hour
1 to < 1.5 hours
1.5 to < 2 hours
> 2 hours
TOOL #8
Reproduced with Permission
Supplement S2
Modified Leisure Time Physical Activity Questionnaire
________________________________________________________________
Please think back to the past 4 weeks. During a typical week in the past 4 weeks, how
many minutes per day as a rule do you do the following types of physical activity or
exercise for more than 10 minutes at a time during your free time?
a) STRENUOUS PHYSICAL ACTIVITY – heart beats rapidly (i.e. brisk walking
uphill, jogging, sports like hockey, soccer, basketball, cross-country skiing, judo,
vigorous swimming, long distance bicycling).
Day | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total |
Minutes |
b) MODERATE PHYSICAL ACTIVITY – not exhaustive (i.e. fast walking, doubles
tennis, easy bicycling, volleyball, easy swimming, aqua-fit classes, popular and
folk dancing).
Day | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total |
Minutes |
c) MILD PHYSICAL ACTIVITY – minimal effort (i.e. yoga, archery, curling, bowling,
golf, horseshoes, easy walking)
Day | 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total |
Minutes |
Supplement S3
Bland-Altman plot for minutes per week spent in MVPA for:
(A) ActiGraph versus EVS and (B) ActiGraph versus mLTPA-Q
A B
Healthy Eating Assessment1
The purpose of this assessment is to identify eating patterns, health benefit score and to provide a guide to start the
conversation of eating healthy to prevent chronic diseases.
• By answering these questions, you will learn how healthy you are or get you ready to start a conversation with your
health care provider on how to make improvements.
• Over the past few weeks, average what you ate or drank and circle one answer for each of the questions below. Add up
your score and see where you are in the health benefit zone on page 2.
1. How would you rate your overall habits of eating healthy foods?
Poor | Fair | Good | Very Good | Excellent |
1 | 2 | 3 | 4 | 5 |
2. How many times a day did you eat fast/fried food/or packaged snacks high in fat/salt/or sugar?
6 or more times | 4-5 times | 2-3 times | 1 time | Less than 1 |
1 | 2 | 3 | 4 | 5 |
3. How many servings (1 serving = 1/2 cup) of fresh, canned, frozen or dried fruit did you eat each day?
Less than 1 | 1 time | 2-3 times | 4-5 times | 6 or more times |
1 | 2 | 3 | 4 | 5 |
4. How many servings of fresh, canned, frozen or dried vegetables did you eat each day?
Less than 1 | 1 time | 2-3 times | 4-5 times | 6 or more times |
1 | 2 | 3 | 4 | 5 |
5. How many regular soda, sweet tea, juice, energy/sports drinks, sweetened-coffee or other sugar
sweetened beverages did you drink each day?
6 or more times | 4-5 times | 2-3 times | 1 time | Less than 1 |
1 | 2 | 3 | 4 | 5 |
6. How many times a day did you eat regular (not low-fat) snack chips or crackers?
6 or more times | 4-5 times | 2-3 times | 1 time | Less than 1 |
1 | 2 | 3 | 4 | 5 |
1Adapted from: Paxton, et al. (2011). Starting the conversation: performance of a brief dietary assessment and intervention tool
for health professionals. American journal of preventive medicine, 40(1), 67-71.
7. How many times a day did you eat sweet foods (not the low-fat kind) or desserts, like chocolate
or ice cream, and other sweets?
6 or more times | 4-5 times | 2-3 times | 1 time | Less than 1 |
1 | 2 | 3 | 4 | 5 |
8. How much margarine, butter, lard or muktuk/meat fat did you add to vegetables, bannock, potatoes,
bread, corn or dried meat?
Heaping amount | A lot | Some | Very little | None |
1 | 2 | 3 | 4 | 5 |
9. How many times a day did you eat dairy products (milk, unsweetened yogurt, low fat cheese)?
Less than 1 | 1 time | 2-3 times | 4-5 times | 6 or more times |
1 | 2 | 3 | 4 | 5 |
10. How many times a day did you eat meat/fish/beans? (Circle one number)
Less than 1 | 6 or more times | 4-5 times | 1 time | 2-3 times |
1 | 2 | 3 | 4 | 5 |
Determine your Health Benefit score here and Next Steps:
Total Score | 10-19 | 20-29 | 30-39 | 40-50 |
Health Benefit Zone | Needs Improvement | Fair | Good | Excellent |
Action Plan | Take this questionnaire with you when you meet with your healthcare provider to create an action plan that fits your lifestyle. |
Keep up the great work and continue to make healthy food choices. |
If you would like this information in another official language, contact us at 1-855-846-9601.
Si vous voulez ces informations dans une autre langue officielle, téléphonez-nous au 1-855-846-9601.
January 2017
References:
Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high selfesteem
cause better performance, interpersonal success, happiness, or healthier lifestyles?
Psychological Science in the Public Interest, 4, 1-44.
Canadian Society for Exercise Physiology (2020). The Canadian physical activity, fitness and
lifestyle approach, PASB-Q, 3rd edition. Ottawa, Canada: Canadian Society for Exercise
Physiology.
Donatelle, R.J., Chow, A.F., & Kolen-Thompson, A.M. (2019). Health the basics: assess yourself
taking charge – managing your risk for chronic disease: Understanding your risk for
CVD? Pearson; 7th Canadian Edition
Donatelle, R.J., Chow, A.F., & Kolen-Thompson, A.M. (2019). Health the basics: assess yourself
taking charge – managing your blood glucose: are you at risk for diabetes? Pearson; 7th
Canadian Edition, p. 21-25.
Donatelle, R.J., Chow, A.F., & Kolen-Thompson, A.M. (2019). Health the basics: assess yourself
taking charge – managing your alcohol and tobacco use: alcohol and tobacco, are your
habits placing you at risk? Pearson; 7th Canadian Edition
Donatelle, R.J., Chow, A.F., & Kolen-Thompson, A.M. (2019). Health the basics: assess yourself
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