Other: General Health Survey (1991)
Please read the following questions and all the possible answers carefully. Choose the best response for each question and tick the appropriate box.
| 1. | Do you consistently use seatbelts as a driver or passenger in a car? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 2. | Do you consistently avoid eating high fat foods? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 3. | Have you been eating a diet high in fiber? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 4. | Have you been trying to lose weight? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 5. | Do you exercise three times a week for at least 20 minutes each time? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 6. | Do you take precautions against exposure to the sun? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 7. | Do you consistently use sunscreens when in the sun for more than 15 minutes? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 8. | Have you attempted to reduce the amount of stress in your daily life? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
| 9. | Have you quit smoking cigarettes? | |
| a | YES, I quit More than 6 months ago. | ☐ |
| b | YES, I quit LESS than 6 months ago. | ☐ |
| c | NO, but I intend to quit in the next 30 days. | ☐ |
| d | NO, but I intend to quit in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to quit in the next 6 months. | ☐ |
| f | I was NEVER a cigarette smoker. | ☐ |
| 10. | Do you examine yourself for warning signs of cancer (for example, breast, testicles, skin)? | |
| a | YES, I have been for More than 6 months. | ☐ |
| b | YES, I have been, but for LESS than 6 months. | ☐ |
| c | NO, but I intend to in the next 30 days. | ☐ |
| d | NO, but I intend to in the next 6 months. | ☐ |
| e | NO, and I do NOT intend to in the next 6 months. | ☐ |
Scoring
For all questions:
| Answer choice (A) | Maintenance Stage |
| Answer choice (B) | Action Stage |
| Answer choice (C) | Preparation Stage |
| Answer choice (D) | Contemplation Stage |
| Answer choice (E) | Precontemplation Stage |
References
Nigg, C.R., Burbank, P., Padula, C., Dufresne, R., Rossi, J. S., Velicer, W. F., Laforge, R. G. & Prochaska, J. O. (1999). Stages of change across ten health risk behaviors for older adults. The Gerontologist, 39, 473-482.