FA N TA S T I C L I F E S T Y L E C H E C K L I S T

Pace an ‘X’ beside the box which best describes your behaviour over the last couple of weeks. Explanations of
questions and scoring are provided on the next page.

I have someone to talk

some of fairly almost
to about things that are almost never seldom
FAMILY the time often always
important to me
FRIENDS
I give and some of fairly almost
almost never seldom
receive affection the time often always

I am vigorously active 5 or
1-2
for at least 30 minutes less than 3 times/ 4 times/ more
times/
per day e.g., running, once/week week week times/
week
cycling, etc week
ACTIVITY
I am moderately 5 or
1-2
active (gardening, less than 3 times/ 4 times/ more
times/
climbing stairs, walking, once/week week week times/
week
housework) week

I eat a balanced diet some of fairly almost

almost never seldom
(see explanation) the time often always

I often eat excess 1)

none
sugar, or 2) salt, or three of one of
NUTRITION four of these two of these of
3) animal fats, or 4) these these
these
junk food
I am within kg of not within 8 kg 6 kg 4 kg 2 kg
my healthy weight 8 kg (20 lbs) (15 lbs) (10 lbs) (5 lbs)

none
more than 1 – 10 none in none in
in the
I smoke tobacco 10 times/ times/ the past 6 the past
past 5
week week months year
years

I use drugs such as

sometimes never
marijuana, cocaine
TOBACCO
TOXICS
I overuse prescribed or fairly only almost
almost daily never
‘over the counter’ drugs often occasionally never

I drink caffeine-
some of fairly
containing coffee, almost never seldom always
the time often
tea or cola

CANADIAN SOCIETY FOR EXERCISE PHYSIOLOGY C S E P. C A

 My average alcohol
more than 13-20 11-12 8-10 ä‡Ç
intake per week is
20 drinks drinks drinks drinks drinks
(see explanation)
ALCOHOL
I drink more than four fairly only almost
almost daily never
drinks on an occasion often occasionally never

I drive after drinking sometimes never

I sleep well and some of fairly almost

almost never seldom
feel rested the time often always
some of most of
I use seatbelts never seldom always
SLEEP the time the time

SEATBELT I am able to cope with some of fairly almost

almost never seldom
STRESS the stresses in my life the time often always

SAFE SEX I relax and enjoy some of fairly almost

almost never seldom
leisure time the time often always

I practice safe sex some of fairly almost

almost never seldom
(see explanation) the time often always

almost fairly some of almost

I seem to be in a hurry seldom
TYPE OF always often the time never
BEHAVIOUR almost fairly some of almost
I feel angry or hostile seldom
always often the time never
I am a positive or some of fairly almost
almost never seldom
optimistic thinker the time often always

almost fairly some of almost

INSIGHT I feel tense or uptight seldom
always often the time never

almost fairly some of almost

I feel sad or depressed seldom
always often the time never

I am satisfied with my some of fairly almost

CAREER almost never seldom
job or role the time often always

Total the X’s in each

STEP 1
column
Multiply the totals by
The numbers indicated x x x x
STEP 2 o
(write your answer in the 1 2 3 4
box below)

Add your scores across

STEP 3
The bottom for your

Grand total o =

CANADIAN SOCIETY FOR EXERCISE PHYSIOLOGY C S E P. C A