Spiritual_Wellness_Holistic_Health_and_the_Practic

172 Philosophical Foundations of Health Education
EXHIBIT 17.2 Stage of Change Assessment Questionnaire
Please provide the following information.
Age ———— Gender ———— Height ———— Weight ————
Year in college ———— Date –———————————————
Please answer the following questions.
1. In the past 6 months, have you ever changed your “lifestyle habits” in an attempt to
improve your health?
Yes
No (If “no,” skip to question #6)
2. What “lifestyle habit(s)” have you changed in the past 6 months?
3. IF YES (#1), are you currently making those efforts?
Yes
No (If “no,” skip to question #6)
4. IF YES (#1), how long have you been successfully able to alter your “lifestyle habits”?
Less than 30 days
1–6 months
7–12 months
Over a year
5. IF YES (#1), would you say you are currently “healthier” as a result of your “lifestyle
habit” changes?
Yes
No
6. In the past month, have you thought about changes you could make to improve your
health?
Yes
No
7. How confident are you that you will make some of these changes (#6) during the next
month?
Very confident
Somewhat confident
Mildly confident
Not at all confident
8. What affects your confidence that you will be able/not be able to make some of these
changes during the next month?