Appendix E

Healthy Lifestyle Questionnaire

Name:______________________________ Date:_________________________

Please indicate your weekly lifestyle behaviors for each of the following:

Physical Activity/Exercise: Give yourself 2 points for each day per week you engage in physical activity/exercise (brisk walking, cycling, jogging, swimming, aerobic dancing, active sports, gardening) for at least 30 minutes. (10 point maximum)	______
Television watching: Give yourself 10 points if you watch 7 or less hours per week. Subtract 2 points for each additional 3 hours per week of television watched.	______
Tobacco use: Give yourself 10 points if you do not currently use tobacco products;5 points if you smoke a pipe or cigars only, or currently smoke less than 10 cigarettes per day; 0 points if you currently smoke ten or more cigarettes daily.	______
Seat belt use: Give yourself 10 points if you always wear your seat belt when driving or riding in a car; most of the time = 8 points; half the time = 5 points; seldom or never = 0 points. (10 points maximum)	______
Mental, emotional, spiritual health: Give yourself 10 points for engaging in one hour of activities that promote mental, emotional and/or spiritual health per week (e.g., worship, fellowship, counseling, meditation, yoga, Tai Chi, journal writing); 30 minutes per week = 5 points (10 points maximum)	______
Social support: Give yourself 2 points for each time (or 10 minutes per week) you share problems or joys and/or get help from a good social support system (family, friends, church, etc.). (10 points maximum)	______
Sleep: Give yourself 10 points if you average 7-9 hours of sleep per night; 7 points for 6 or 10 hours per night; 4 points for 5 or 11 hours per day. (10 points maximum).	______
Eating: Give yourself 2 points for every serving of vegetables (1/2 cup) and/or fruit you eat per day (18 points maximum).	______
Water: Give yourself 2 points for every 8 oz.cup of water and/or juice you drink per day. (10 points maximum).	______
Rate your overall health (circle the appropriate number) (10 points maximum) /_____10_____/_____8_____/_____5_____/_____2_____/_____0_____/ Total-> Excellent Good Poor	______

Total your points (up to 100) to determine your relative health lifestyle

90 and higher
80-89
70-79
60-69
Less than 60

= excellent
= very good
= good
=acceptable
= need more attention

Appendix F

Community Ability to Create Wellness Changes (Social Capital)

We appreciate your efforts on behalf of a better quality of life in the _________ area. Your response to the items on this page will be helpful. Place a check along the line to indicate your feelings about this community-building process. This survey is anonymous.

INDICATE YOUR SENSE OF:

Commitment to the process

_____________________________________________________________________________________________
None Very Strong

Enjoyment of the process

_____________________________________________________________________________________________
None Very Strong

Confidence that process will achieve outcomes

_____________________________________________________________________________________________
None Very Strong

Shared purpose among group members

_____________________________________________________________________________________________
None Very Strong

Your contribution is valued

_____________________________________________________________________________________________
Not at all Very Strong

You tend to trust the process

_____________________________________________________________________________________________
Not at all Very Strong

Any other comments about the group_______________________________________________________

_____________________________________________________________________________________________

Thank you for completing this survey.

Wheeling Walks Training Manual

Appendices E and F

Appendix E

Healthy Lifestyle Questionnaire

Appendix F

Community Ability to Create Wellness Changes (Social Capital)