Readiness to change

The purpose of this questionnaire is to investigate aspects of addressing general health issues. There are no right or wrong answers, so please consider each question carefully and answer as honestly as you can.

Below is a readiness scale where 0 represents being not at all ready to address a chosen health issue and 10 represents being extremely ready to address the chosen health issue.

 0  1  2  3  4  5  6  7  8  9 10
                   
Not at all
ready 		Extremely
ready

 

• = Required fields

First Name
•		 Last Name
•		 Email Address
•

Section A: Choose ONE general health goal from the list below that you feel ready to take some action on

1. Please choose one General health goal that you think would benefit your health if you took some action to address it. Choose something that you would rate as a 6 or higher on the readiness scale above. •

Manage weight Manage medications Manage stress
Manage blood glucose levels Maintain bone density Improve nutrition
Improve eating habits Improve sleep
 Increase movement
Increase energy levels Increase personal time Increase Flexibility
Decrease cholesterol
 Decrease blood pressure
 Decrease alcohol
Decrease caffeine Decrease smoking Other
Please specify
Please answer the following questions with regard to the general goal that you chose in Question 1.
2. How ready are you to do something to address this general goal?•
 0  1  2  3  4  5  6  7  8  9 10
Not at all
ready		 Extremely
ready
3. How important is it for you to do something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
important		 Extremely
important
4. How confident are you that you can do something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
confident		 Extremely
confident
5. How committed are you to doing something that can address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
committed		 Extremely
committed
6. To what extent is the next 7 days a good time to start doing something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
a good time		 Extremely
good time
7. Having answered the questions above, has your overall readiness (Question 2) changed? •

Yes No
8. If yes, how ready are you to do something to address this general goal?
 0  1  2  3  4  5  6  7  8  9 10
Not at all
ready		 Extremely
ready

Section B: Choose a different general health goal that you feel you are NOT ready to take action on

9. Please choose a different general health behaviour from the list below that you think would benefit your health if you took some action to address it. Choose something that you would rate as a 5 or lower on the readiness scale. •

Manage weight Manage medications  Manage stress 
Manage blood glucose levels Maintain bone density  Improve nutrition 
Improve eating habits Improve sleep Increase movement 
Increase energy levels  Increase personal time Increase Flexibility 
Decrease cholesterol Decrease blood pressure Decrease alcohol 
Decrease caffeine Decrease smoking Other
Please specify
10. How ready are you to do something to address this general goal?•
 0  1  2  3  4  5  6  7  8  9 10
Not at all
ready		 Extremely
ready
11. How important is it for you to do something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
important		 Extremely
important
12. How confident are you that you can do something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
confident		 Extremely
confident
13. How committed are you to doing something that can address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
committed		 Extremely
committed
14. To what extent is the next 7 days a good time to start doing something to address this general goal? •
 0  1  2  3  4  5  6  7  8  9 10
Not at all
a good time		 Extremely
good time
15. Having answered the questions above, has your overall readiness (Question 10) changed? •

Yes No
16. If yes, how ready are you to do something to address this general goal?
 0  1  2  3  4  5  6  7  8  9 10
Not at all
ready		 Extremely
ready
17. Do you have one or more chronic health conditions that require ongoing management? •

Yes No
18. What is your gender? •
Male
Female		 19. What is your age group? •
18-24
25-34
35-44
45-54
55-64
65+		 20. What is the highest level of education that you completed? •
Less than High School
High School
Technical Certificate or Diploma
Undergraduate University Degree
Post-graduate University Degree
21. Are you an accredited heath professional?•
Yes
No		 22.  If yes, please specify

If other, please specify
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