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Executive Physical Wellness Profile

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General

Do you believe your current lifestyle:

Of all the possible actions you could take to prevent disease and maintain/enhance your health, how much do you estimate you are currently doing?:

Which area of behavior would you most like to change to improve your health?:

Weight Management

Have you ever lost ten percent of your weight through dieting/exercise and then gained it back?:

Have you recently had a significant loss of weight, and you're not sure why?:

How do you feel about your current weight?:

Exercise

Do you accumulate at least 30 minutes of physical activity on most (5-6) days of the week? The activity must be moderate to high intensity like walking, house work, cycling, stair climbing, swimming, running or sport games.:

Do you warm up before and cool down after aerobic exercise?:

Do you participate in strength training activities (weight lifting)?:

How often do you stretch your muscles in order to gain flexibility? :

How often do you perform abdominal exercises, such as sit-ups, intended to strengthen the abdomen?:

What is the biggest barrier to increasing and/or maintaining your level of exercise?:

Nutrition

How often do you eat breakfast?:

On average, how many servings of high calcium foods do you eat each day? Foods such as milk, cheese, yogurt and green leafy vegetables are high in calcium.:

On average, how many servings of high fiber foods do you eat each day? Foods such as beans, whole grains, cereals, fruits and vegetables are high in fiber.:

On average, how many servings of high fat foods do you eat each day? Foods such as whole milk, cheese, egg yolks, red meat, fried foods and some desserts are high in fat.:

How often do you choose low fat or low cholesterol foods?:

How often do you add salt to your cooking or add it to your food at the table?:

How often do you read nutrition labels on food packages?:

On average, how many drinks do you have in one setting? A drink is a 12 oz. bottle or can of beer, a 5 oz. glass of wine, a 12 oz. wine cooler, or a shot of liquor. (If you answer "Less than 1 drink/week," go to question 22.):

On average, how many days per week do you drink alcohol?:

How many times in the last month did you ride in a car when the driver was under the influence of drugs or alcohol?:

Safety

How many times in the last month did you ride in a car when the driver was under the influence of drugs or alcohol?:

What percent of the time do you buckle your safety belt when riding in a car?:

How would you describe your driving behavior?:

How often do you wear sunscreen or protective clothing when you are in the sun?:

When riding a bicycle, motorcycle, or similar vehicle, how often do you wear a helmet?:

Does your home have a smoke detector and/or CO2 detector that works?:

When lifting objects, even when they are not very heavy, do you lift them properly?:

Tobacco

What is your exposure to second-hand smoke? :

Do you use cigarettes, cigars, e-cigarettes, pipes, or smokeless tobacco such as chewing tobacco, snuff or pouches?:

What is the primary reason you have not quit smoking?:

Stress

During the past year, how much effect has stress had on your health?:

Do you think your current level of stress is high enough to affect your health or quality of life?:

How effective do you think you are in dealing with the stress in your life?:

Do your sleep patterns promote good health?:

How often do you feel tense, anxious or upset?:

In general, do you have emotional support from others to help you deal with stress?:

How often do friends or relatives suggest that you should slow down, take life easier or relax more?:

How often do you find yourself getting irritated or annoyed with others? :

How often do you feel a chronic sense of struggle with daily events?:

Have you suffered a personal loss or misfortune in the past year that had a serious impact on your life?:

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