|
Select
one number for each question:
4=Very likely
3=Somewhat likely
2=Not very likely
1=Not at all likely
|
|
1. I buy heart healthy snacks when
they are available (for example, pretzels, cereals,
yogurt, 1% or skim milk, fresh fruit, 100% juice,
raisins or other dried fruit, NOT candy, chips,
pastry, etc.)
|
4 3 2 1 |
2. If I had a 5-minute break I would
use it for a personal activity—like stretching,
yoga, or a walk—if there were a place to do it.
|
4 3 2 1 |
3. I would eat fruit if available
at our staff meetings.
|
4 3 2 1 |
4. I would participate in group activities
encouraging healthy eating or physical activity
if they were offered to staff
|
4 3 2 1 |
5. I would use resource guides for
healthy eating or physical activity (for example,
how-to books, videos, and recipes) if they were
available.
|
4 3 2 1 |
6. I am satisfied with my current
state of health.
|
4 3 2 1 |
7. I make time for 20 or more minutes
of physical activity most days of the week.
|
4 3 2 1 |
8. I don’t think about health when
deciding what to eat.
|
4 3 2 1 |
9. It’s hard for me to get as much
exercise as I should.
|
4 3 2 1 |
10. I try to look for healthier foods, but usually
eat whatever is available.
|
4 3 2 1 |
11. I don’t know what is meant by “worksite wellness”.
|
4 3 2 1 |
12. Healthier people are more productive at work.
|
4 3 2 1 |
13. Paying attention to eating healthy and getting
exercise is a lot of trouble.
|
4 3 2 1 |
14. I know what it takes to lead a healthy lifestyle.
|
4 3 2 1 |
15. Whether or not to live a healthy lifestyle
is completely up to the individual.
|
4 3 2 1 |
Additional comments are welcome!
Please write them on a separate sheet of paper.
If you want to know more about this program and
how you can help, please contact your supervisor.
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