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1. |
Do you consistently use
seatbelts as a driver or passenger in a car? |
|
| a |
YES, I have been for More than 6 months. |
 |
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
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2. |
Do you consistently avoid
eating high fat foods? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
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3. |
Have you been eating a diet
high in fiber? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
|
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4. |
Have you been trying to lose
weight? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
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5. |
Do you exercise three times a
week for at least 20 minutes each time? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
|
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6. |
Do you take precautions
against exposure to the sun? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
|
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7. |
Do you consistently use
sunscreens when in the sun for more than 15 minutes? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
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8. |
Have you attempted to reduce
the amount of stress in your daily life? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
|
| d |
NO, but I intend to in the next 6 months. |
|
| e |
NO, and I do NOT intend to in the next 6 months. |
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9. |
Have you quit smoking
cigarettes? |
|
| a |
YES, I quit More than 6 months ago. |
|
| b |
YES, I quit LESS than 6 months ago. |
|
| c |
NO, but I intend to quit in the next 30 days. |
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| d |
NO, but I intend to quit in the next 6 months. |
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| e |
NO, and I do NOT intend to quit in the next 6 months. |
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I was NEVER a cigarette smoker. |
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10. |
Do you examine yourself for
warning signs of cancer (for example, breast, testicles,
skin)? |
|
| a |
YES, I have been for More than 6 months. |
|
| b |
YES, I have been, but for LESS than 6 months. |
|
| c |
NO, but I intend to in the next 30 days. |
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| d |
NO, but I intend to in the next 6 months. |
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| e |
NO, and I do NOT intend to in the next 6 months. |
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