HOW IS YOUR HEALTH? A Self Survey
Physical Health
| 1. Do you exercise or play a sport for at least 30 minutes 3 or more times a week? | Y | N |
| 2. Are you the appropriate weight for someone your height and gender? | Y | N |
| 3. Are you satisfied with your current level of energy? | Y | N |
| 4. Do you get 7-9 hours of sleep most nights? | Y | N |
| 5. Do you practice good dental hygiene? | Y | N |
| 6. Do you use sunscreens regularly and limit sun exposure? | Y | N |
| 7. Do you have basic first aid skills? | Y | N |
| 8. Do you try fad weight loss diets? | Y | N |
| 9. Do you minimize your intake of sweets and high-fat foods? | Y | N |
| 10. Do you eat at least 5 servings of fruits and vegetables per day? | Y | N |
| 11. Do you drink enough fluids so that your urine is a pale yellow color? | Y | N |
| NUMBER IN EACH COLUMN | ___ | ___ |
| 1. Do you have one or more persons with whom you can discuss personal concerns, problems, or worries? | Y | N |
| 2. Do you enjoy a variety of activities? | Y | N |
| 3. Do you have several friends that you enjoy spending time with? | Y | N |
| 4. Do you have a "best friend?" | Y | N |
| 5. Do you have trouble asking for help from adults? | Y | N |
| 6. Are you satisfied with your balance between work/school and leisure time? | Y | N |
| 7. Are you satisfied with your romantic life? | Y | N |
| NUMBER IN EACH COLUMN | ___ | ___ |
| 1. Are you interested in, do you keep up to date on social and political issues? | Y | N |
| 2. Do you engage in creative and stimulating activities as much as you would like? | Y | N |
| 3. Are you bored in your classes at school? | Y | N |
| 4. Does school seem "just too hard" for you? | Y | N |
| NUMBER IN EACH COLUMN | ___ | ___ |
| 1. Do you find it easy to laugh? | Y | N |
| 2. Do you hold in your angry feelings without expressing them? | Y | N |
| 3. Do you make decisions with a minimum amount of stress and worry? | Y | N |
| 4. Do you include relaxation time as part of your daily routine? | Y | N |
| 5. Do you think it is OK to feel angry, afraid, joyful or sad? | Y | N |
| 6. Do you feel OK about crying and allow yourself to do so? | Y | N |
| 7. Would you seek help from a professional counselor if needed? | Y | N |
| 8. Are you able to say "no" to people without feeling guilty? | Y | N |
| NUMBER IN EACH COLUMN | ___ | ___ |
| 1. Are you satisfied with your spiritual life? | Y | N |
| 2. Is it difficult for you to accept the values of others when they are different from your own? | Y | N |
| 3. Do you participate in activities which help you examine and develop your spirituality? | Y | N |
| 4. Do you enjoy expressing yourself through art, dance, music, drama, sports, etc.? | Y | N |
| 5. Do you take interest in community, national or world events and do you work to support issues and people of your choice? | Y | N |
| 6. Are you a member of one or more of the following organizations: church, social change group (examples include: NAACP, Green Peace, Save our Rivers, Sierra Club, etc.) or political group (examples include: Young Democrats, Young Republicans, etc.)? | Y | N |
| NUMBER IN EACH COLUMN | ___ | ___ |
1. What area (dimension of health) do you consider to be your "healthiest"?
2. Why did you choose that area/dimension as your "healthiest"?
3. What are three things you could do to maintain this area/dimension as your "healthiest"?
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5. Why did you choose that area/dimension as one in need of improvement?
6. What are three things you could do to improve your health in this area/dimension?
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