Lifestyle questionnaire
Name:
Circle the number that best describes your experience
1=Always 3= Sometimes 5= Never
I regularly skip meals
I overeat
I binge and/or purge
I have/had an eating disorder
I eat throughout the day.
(Breakfast, Lunch, Dinner
Snacks)
1
2
3
4
5
I eat a well-balanced diet
(Vegetables, Grains, Protein,
limited sugar)
1
2
3
4
5
I get seven to eight hours of restful
sleep at least four nights a week.
1
2
3
4
5
I exercise to the point of
perspiration at least twice a week.
1
2
3
4
5
I am the appropriate weight for my
height.
1
2
3
4
5
I drink at least 36 oz of water/liquid
per day
1
2
3
4
5
I drink fewer than three cups of
coffee (or other caffeine-rich drinks)
a day.
1
2
3
4
5
I drink 3+ caffeine drinks a day
I drink 5+ caffeine drinks a day
1
2
3
4
5
I smoke 1-2 cigarettes per day
I smoke less than ½ pack per day
I smoke more than ½ pack per day
I take fewer than five alcohol drinks
a week.
1
2
3
4
5
I don’t take unnecessary
medications/drugs
1
2
3
4
5
I eat junk food / fast food
I eat a lot of fatty foods
I eat a lot of sugar
I eat only white bread / processed food
I don’t eat Vegetables / Fruit
I oversleep
I get less than 7 hours sleep a night
I get less than 4 hours of sleep a night
I don’t exercise
I do not smoke cigarettes
I can’t exercise because
I exercise once a week
I exercise, but don’t perspire
I am overweight
I am underweight
My weight goes up and down a lot
I drink sugar drinks
I drink only caffeine drinks
I drink only Soda / Juice
I drink less than 36 oz of water per day
I drink 5+ alcohol drinks a week
I am worried about my drinking
I blackout from drinking
I start the day with alcohol just to feel normal
I take medications after illness is gone
I take other people’s medications
I use recreational drugs
I use illegal drugs
I have at least one relative within 50
miles, on whom I can rely.
1
2
3
4
5
I have no relatives within 50 miles
I avoid my relatives
My relatives are the source of my stress
I give and receive affection
regularly.
1
2
3
4
5
I do not give and receive affection regularly
I do not want affection
Affection is not tolerable
I have an income adequate to meet
basic expenses.
1
2
3
4
5
I do not have income adequate to meet basic expenses.
I have adequate income, but I don’t manage money well
I get strength from my religious
beliefs (if important to you)
1
2
3
4
5
I do not follow any religion (not important to me)
I don’t get strength from my religious beliefs.
I don’t have time for religion
I regularly attend club or social
activities.
1
2
3
4
5
I do not attend social activities, but I want to
I do not want to attend club or social activities.
I have a network of friends and
acquaintances.
1
2
3
4
5
I do not have a network of friends and acquaintances.
I do not want a network of friends and acquaintances.
I have one or more friends to
confide in about personal matters.
1
2
3
4
5
I do not have one or more friends to confide
I cannot trust my friends
I am in good health (including eyesight, hearing, teeth).
1
2
3
4
5
I am concerned about my health:
I am able to speak openly about my
feelings when angry or worried.
1
2
3
4
5
1
2
3
4
5
I do something for fun at least once
a week.
1
2
3
4
5
I am able to organize my time
effectively.
1
2
3
4
5
I take some quiet time for myself
during the day.
1
2
3
4
5
I have regular conversations with
the people I live with about
domestic issues - for example,
chores and money.
I have difficulty speaking openly about my feelings when
angry or worried.
I don’t live with anyone
We don’t have regular conversations
I avoid conversations – too much conflict
My partner avoids conversations
I try to have fun once or twice a month
I don’t have any fun
Nothing is fun anymore
I have difficulty organizing my time
I don’t take quiet time during the day.
I don’t want quiet time during the day.