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"CPRC - A research organization dedicated to helping people change their behavior for living longer, healthier lives"

 
Other: General Health Survey (1991)

Please read the following questions and all the possible answers carefully.  Choose the best response for each question and tick the appropriate box.

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.

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.

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.

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.

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.

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.

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.

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.

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.

d

NO, but I intend to quit in the next 6 months.

e

NO, and I do NOT intend to quit in the next 6 months.

I was NEVER a cigarette smoker.

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.

d

NO, but I intend to in the next 6 months.

e

NO, and I do NOT intend to in the next 6 months.

 

Scoring

For all questions:
Answer choice (A) - Maintenance Stage
Answer choice (B) - Action Stage
Answer choice (C) - Preparation Stage
Answer choice (D) - Contemplation Stage
Answer choice (E) - Precontemplation Stage

 

References

Nigg, C.R., Burbank, P., Padula, C., Dufresne, R., Rossi, J. S., Velicer, W. F., Laforge, R. G. & Prochaska, J. O. (1999). Stages of change across ten health risk behaviors for older adults. The Gerontologist, 39, 473-482.