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Houston, Texas

People discussing health of women with disabilities
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Health Promoting Behaviors Checklist for Women with Disabilities--Diet

How often do you:

1. Have a say about what kind of food is prepared in your home?

_____rarely

_____sometimes

_____often

2. Choose a diet that is best for your health?

_____rarely

_____sometimes

_____often

3. Eat at least five servings of fruits and vegetables daily?

_____rarely

_____sometimes

_____often

4. Limit the amount of fat in your diet?

_____rarely

_____sometimes

_____often

5. Read labels to identify the nutrients in packaged foods?

_____rarely

_____sometimes

_____often

6. Eat regularly?

_____rarely

_____sometimes

_____often

7. Have you received information from a dietician or other health care provider about nutritional requirements for you?

_____no

_____yes

8. Do you follow a diet recommended by your doctor or other health care provider?

_____no

_____yes

What is your level of self-confidence for diet?

1. How confident are you that you can eat a well-balanced diet?

_____choose a number between 1 (not at all confident) and 10 (totally confident)

2. How confident are you that you could follow a diet if recommended by your doctor or dietician?

_____choose a number between 1 (not at all confident) and 10 (totally confident)

3. How confident are you that you can select foods that will help you maintain your ideal weight?

_____choose a number between 1 (not at all confident) and 10 (totally confident)

4. How confident are you that you can select appropriate vitamins and supplements when needed to maintain your health?

_____choose a number between 1 (not at all confident) and 10 (totally confident)

5. How confident are you that you can identify the nutrients in packaged food by reading the labels?

_____choose a number between 1 (not at all confident) and 10 (totally confident)

What would it take to raise your level of self-confidence for diet?

Physical Activity

Smoking

More information on diet...

Health Behaviors Table of Contents

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