Name:_____________________

Health Appraisal
Give yourself one point for each statement that correctly reflects your lifestyle. If it does not
reflect your lifestyle, write a zero or leave it blank.

Physical Health
______1. I exercise at least three times a week for at least 30 minutes.
______2. I wear a seatbelt when riding in a motor vehicle.
______3. I wear a helmet when riding a bicycle or a skateboard.
______4. I floss daily.
______5. I eat at least five servings of fruits and vegetables each day.
______6. I do not use any tobacco products.
______7. I get at least eight hours of sleep each night.
______8. I have regular check-ups with my healthcare provider.
______9. I have regular check-ups with my dentist.
______10. I do not skip meals.

Score: _____________

Mental Health
______1. I enjoy learning.
______2. I ask questions in class.
______3. I enjoy learning new things.
______4. I use appropriate decision-making skills when making important decisions.
______5. I manage stress in a healthy manner.
______6. I seek and accept feedback from others on my work.
______7. I accept responsibility for my mistakes.
______8. I recognize and capitalize on my personal strengths.
______9. I utilize techniques that support my individual learning style.
______10. I offer to help others when I am able.

Score: _____________

Social Health
______1. I enjoy the company of others.
______2. I have at least one close friend.
______3. I am a good listener.
______4. I am a trustworthy confidant.
______5. I am honest with others.
______6. I do not allow others to pressure me to do things that I do not want to do.
______7. I use assertive communication skills when appropriate.
______8. I cooperate with family members to complete household responsibilities.
______9. I appreciate diversity and respect differences in others.
______10. I seek support from my network of friends and family members when I need it.

Score: _____________

Emotional Health
______1. I have a positive attitude.
______2. I can express my feelings and emotions with ease.
______3. I can accept personal faults and failures.
______4. I like and feel secure with who I am.
______5. I make decisions based on my values and beliefs.
______6. I feel that I am well liked by my peers.
______7. I address a conflict without hurting the feelings of others.
______8. I express my emotions in a mature manner.
______9. I am confident in my abilities.
______10. I demonstrate sincere empathy for others.

Score: _____________

Total the points for each section and record your score. Use the following scale to assess your
score for each section.

9-10= Excellent
7-8= Good
5-6= Fair
0-4= Needs Improvement- Re-examine your habits and behaviors in this area and look for any
changes that could improve your health.