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. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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2. |
Do you consistently avoid eating high fat foods? | |
| a | YES, I have been for More than 6 months. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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3. |
Have you been eating a diet high in fiber? | |
| a | YES, I have been for More than 6 months. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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4. |
Have you been trying to lose weight? | |
| a | YES, I have been for More than 6 months. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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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. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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6. |
Do you take precautions against exposure to the sun? | |
| a | YES, I have been for More than 6 months. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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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. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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8. |
Have you attempted to reduce the amount of stress in your daily life? | |
| a | YES, I have been for More than 6 months. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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9. |
Have you quit smoking cigarettes? | |
| a | YES, I quit More than 6 months ago. |
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| b | YES, I quit LESS than 6 months ago. |
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| 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. |
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| b | YES, I have been, but for LESS than 6 months. |
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| 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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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.
