CAPITOL MEDICAL CENTER COLLEGES, INC. #4 Sto.

Domingo Avenue, Quezon City Name (optional): _______________________________________ Date: ____________ Age: _______ Sex: __________ Year level: _______

I. ASSESSMENT OF HEALTH PRACTICE Directions: Please put a check mark on the choice that best corresponds to your answer.

Definition & Numerical Value: Always means all the time Often means frequently Sometimes means occasionally Seldom means rarely Never means not at all DIET 1. How often do you eat daily? ___ A. 1- 2 times ___ B. 3-4 times ___ C. 4-5 times ___ D. Others: (Specify) ___________ 2. Do you eat on time? ___A. Always ___B. Often ___C. Sometimes ___D. Seldom ___E. Never 3. Do you eat breakfast? ___A. Always ___B. Often ___C. Sometimes ___D. Seldom ___E. Never

4. If your answer in # 2 is Always, Often, Sometimes, and Seldom, How many times in a week?
___A. Everyday ___B. Twice a Week ___C. 3- 4 times a week ___D. 5-6 times a week

5. What food do you eat often times? (Rate yourself from 1 as the lowest and 5 as the highest and
put a check (/) mark on the appropriate scale found at the right side of each statement.) FOODS Water Coffee / Milk / Chocolate drink Fruit juices Soft drinks Rice Pasta Bread, sandwiches Cereals, oatmeal Egg Vegetables Fruits Fish/ seafoods Meat/ Poultry products Fast foods EXERCISE 1. Do you exercise regularly? ___A. Always ___B. Often ___C. Sometimes ___D. Seldom ___E. Never If your answer is either letter A, B, C, or D, please answer numbers 2, 3, 4. If your answer is NEVER, please proceed to the next section. BREAKFAST LUNCH SNACKS SUPPER

2. Referring to your answer in #1, how many times do you exercise? ( Do not answer if your answer
in #1 is NEVER) ___ A. Once a week ___ B. Twice a week ___ C. Thrice a week - more ___ D. Others: (Specify) _________________ 3. What kind of exercise? ___A. Strength/ Resistance Exercise (Body Building, Weight Lifting) ___B. Flexibility Exercise (Stretching, Pilates) ___C. Cardiovascular Exercise (Aerobics, Brisk Walking, Swimming, Cycling, Climbing Stairs) ___D. Balance Exercise (Yoga, Trampolines) ___E. Others (specify) ____________________________________

4. Referring to your answer in #3, how many hours do you allot when exercising? ( Do not answer if
your answer in #1 is NEVER) ___ A. 15-30 minutes ___ B. 31- 1 hour ___ C. More than an hour ___ D. Others: (Specify) ___________________

NUMBER OF HOURS OF SLEEP 1. How many hours of sleep do you get daily? ___ A. 1-2 hours ___ B. 3-4 hours ___ C. 5-6 hours ___ D. 7-10 hours ___ E. more than 10 hours 2. Do you sleep late? ___A. Always ___B. Often ___C. Sometimes ___D. Seldom ___E. Never PERSONAL HYGIENE 1. How many times do you take a bath? ____A. Once a day ____B. Twice a day ____C. Thrice a day ____D. Never ____E. Others: (Specify) __________________________________

2. When do you wash your hands? (Put a check (/) mark on the appropriate scale found at the right
side of each statement.) Hand Hygiene After using things that is not yours After talking or touching someone who is sick Before and after eating After touching the garbage can After touching animals and animal wastes Before and after handling foods Before and after handling a patient Before and after assisting a procedure or surgery After using the toilet/commode, nappy changing/handling potties After blowing your nose, coughing, sneezing After contact with blood or body fluid Before and after handling any wounds or dressings, or any contraptions of patients ALWAYS OFTEN SOMETIMES SELDOM NEVER

3. Do you apply any products to protect your skin? ___A. Always ___B. Often ___C. Sometimes ___D. Seldom ___E. Never How often do you get dental check-ups? ___ A. 1-2 times per year ___ B. Once a month ___ C. Once every 5 years ___ D. Others: (Specify) 4. How many times do you brush your teeth? ____A. Once a day ____B. Twice a day ____C. Thrice a day ____D. Others: (Specify)_________ ____E. Never STRESS MANAGEMENT 1. What causes your stress? (Put a check (/) mark on the appropriate scale found at the right side of each statement.) NATURE OF PROBLEM Family related Finances School related (other than duty schedule) Peer related Duty schedule changes Community related (e.g. Noisy environment, crowded, untidy) of each statement.) STRESS MANAGEMENT Meditation/ Praying Watching Movies, TV shows Sleeping Travelling Shopping Eating Reading Listening to music Smoking Drinking alcoholic beverages ALWAYS OFTEN SOMETIMES SELDOM NEVER ALWAYS OFTEN SOMETIMES SELDOM NEVER

2. How do you manage stress? (Put a check (/) mark on the appropriate scale found at the right side