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Healthy Living Questionnaire 2011 Mod-Word 09-19

Questionnaire to assess health of living

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Megan Brown
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470 views3 pages

Healthy Living Questionnaire 2011 Mod-Word 09-19

Questionnaire to assess health of living

Uploaded by

Megan Brown
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Modified from the Healthy Living Questionnaire 2011 (SAMHSA)

Name: Date:

Are you working on health goals in any of the following areas?: Mental Health Check-ups Exercise
Healthy Foods Sex Medications Smoking Dental Safety

1. In general, how would you rate your health during the past 4 weeks?
6. Excellent 5. Very Good 4. Good 3. Fair 2. Poor 1. Very Poor

2. During the past 4 weeks, how much did physical health problems limit your usual physical activities (such as
walking or climbing stairs)?
5. Not at all 4. Very little 3. Somewhat 2. Quite a lot 1. Could not do physical activities

3. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away
from home, because of your physical health?
5. None at all 4. A little bit 3. Some 2. Quite a lot 1. Could not do daily work

4. How much bodily pain have you had during the past 4 weeks?
5. None 4. Very mild 3. Mild 2. Moderate 1. Severe 0. Very Severe

5. During the past 4 weeks, how much energy did you have?
5. Very much 4. Quite a lot 3. Some 2. A little 1. None

6. During the past 4 weeks, how much did your physical health or emotional problems limit your usual social
activities with family or friends?
5. Not at all 4. Very little 3. Somewhat 2, Quite a lot 1. Could not do social activities

7. During the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious,
depressed or irritable)?
5. Not at all 4. Slightly 3. Moderately 2. Quite a lot 1. Extremely

8. During the past 4 weeks, how much did personal or emotional problems keep you from doing your usual work,
school or other daily activities?
5. Not at all 4. Very little 3. Somewhat 2. Quite a lot 1. Could not do daily activities

9. During the past 4 weeks, how often did your dinner include at least one vegetable per day?
1. Not at all 2. Very little 3. Sometimes 4. Quite a lot 5. All the time
10. During the past 4 weeks, how often did you engage in some form of exercise?
1. Not at all 2. Very little 3. Sometimes 4. Quite a lot 5. Very frequently

11. During the past 4 weeks, how often did you take all of your medications as
prescribed?
1. Not at all 2. Very little 3. Sometimes 4. Quite a lot 5. All the time or N/A

12. During the past 4 weeks, how often did you brush your teeth twice a day?
1. Not at all 2. Rarely 3. Usually 4. Quite a lot 5. All the time

13. During the past 4 weeks, when in a car, how often did you use a seatbelt?
1. Not at all 2. Very little 3. Sometimes 4. Quite a lot 5. All the time

14. During the past 4 weeks, how often did you smoke?
5. Not at all 4. Very little 3. Sometimes 2. Quite a lot 1. Very frequently

15. During the past 4 weeks, how often did you drive more than 5 miles over the speed limit?
5. Not at all 4. Very little 3. Sometimes 2. Quite a lot 1. Very frequently

16. During the past 4 weeks, how often did you drive while texting or talking on your phone?
5. Not at all 4. Very little 3. Sometimes 2. Quite a lot 1. Very frequently

17. During the past 4 weeks, how often did you use protection with sexual activity?
1. Not at all 2. Rarely 3. Usually 4. All the time or N/A

18. I believe that I can make changes that will improve my physical health. (Circle 1)
Totally agree Agree a little Disagree

19. I believe that I can make changes that will improve my mental health (Circle 1)
Totally agree Agree a little Disagree

Please note that the following questions refer to different time frames than the previous questions.
20. During the past year, how often did you visit your primary care
provider? 0 times 1 time 2 times 3 times 4 or more times

21. During the past 3 months how many times did you visit the Emergency Room?
0 times 1 time 2 times 3 times 4 or more times

The reason was (check all that apply): My mental health My physical health

Questions 1-8 reproduce the SF-8, Copyright: The Medical Outcomes Trust (MOT), Health Assessment Lab (HAL) and QualityMetric Incorporated
22. During the past 3 months, how many times were you admitted to hospital?
0 times 1 time 2 times 3 times 4 or more times

The reason was (check all that apply): My mental health My physical health

 Add up the numbers for questions 1 – 17 to see overall how your healthy lifestyle choices rate.

68 -85 = Excellent; 50 – 67= Very good; 32 – 49 = Good; 17 – 31 = Fair; 0 – 16 = Poor

Thank you for completing these questions!

Questions 1-8 reproduce the SF-8, Copyright: The Medical Outcomes Trust (MOT), Health Assessment Lab (HAL) and QualityMetric Incorporated

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