Part I.

Demographic profile
1. Name: ______________________________(optional)
2. Sex:_0__ M _1__ F
3. Age ______
4. Marital status: __0_ single _1__ married _2__ widow _3__separated
5. Educational level: _0__Elementary __1_high school _2__vocational
6. Monthly Income ( total combined family income a month)_____________

Health Practices Questionnaire

Please check the box whether the questions listed below is part of your usual practices as
5 - Always, 4 - very often, 3 sometimes, 2 seldom, 1 never.

Eating activity 5 4 3 2 1
1. I prefer to buy fresh food than frozen goods
2. I spend money for food that I really need
3. I check nutritional value of foods
4. I exert effort to make eating enjoyable
5. I take vitamins as food supplements
6. I eat 3 times a day
7. I eat fruits and vegetables everyday
8. I prefer to eat the same food everyday
9. I refer to food pyramid for the food I consumed
10. I prefer to eat to eat fast food chains than at
home
1 2 3 4 5
Physical Activities
1. I explore activities I like hiking, caving, and
nature walks

2. I want to be with the people whom I can work
out with

3. I find a class or activity that fits my size and
fitness level

4. I wear comfortable clothing for my activity
5. I buy equipments for my activities
6. I develop a long menu of the things I can do
under different circumstances

7. I stretch regularly
8. I prefer to walk going to work and errands
9. I participate in sports or outdoor group
exercises

10. I prefer to do gardening works


Sleeping Activities

1. I sleep 8 hours a day
2. I invest in good bed and pillows for sleeping
3. I experience insomnia 1 2 3 4 5
4. I have to watch television until midnight before
sleeping
1 2 3 4 5
5. I sleep terribly having a lot of problems on my
head

6. I cannot sleep early because of work 1 2 3 4 5
7. I develop regularly daily bedtime schedule
8. I drink milk before sleeping
9. There are times I wake up in the middle of the
night
1 2 3 4 5
10. I wake up to eat midnight snack 1 2 3 4 5
Medical Activities
1. I have regular screening exams. (papsmear,
mammogram, etc)

2. I am following medical advise
3. I go to the doctor even though it may be
difficult

4. I go for regular check-up when needed 1 2 3 4 5
5. I have dental check up every year
6. I have visual check up every year
7. I take medication as prescribed
8. I used over the counter drugs/natural herbs
even when not advised
1 2 3 4 5
9. I use generic/branded drugs when advised
10. I use natural herbs/OTC drugs when allowed










THANK YOU!!