CENTRAL PHILIPPINE UNIVERSITY

College of Nursing
Graduate Programs
Jaro, Iloilo City

In consortium with

AKLAN POLYTECHNIC COLLEGE

College of Nursing
Kalibo, Aklan

“LIFESTYLE PRACTICES AND HEALTH STATUS OF EMPLOYEES IN THE ONLY

MARITIME SCHOOL IN THE PROVINVE OF AKLAN”

INTERVIEW SCHEDULE

1. PRELIMINARY INFORMATION

Date of the interview: _____ Time Started: ______

Interviewer: ______ Time Ended: ______

Respondent No.: ______

2. PERSONAL CHARACTERISTICS

Name (optional): ______________________________

Age: ___________

Gender: Male: _____ Female: ______

Civil Status:

Single: _____ Married: _____

Widow: _____ Divorced/ Separated: _______

Educational Attainment:

Associate Level: _____ Post graduate level: _____

College level: _____ Doctorate level: _____

Monthly Income:

5000 and below: ______ 10000 – 15000: _____ 20000 – 25000: _____

5001 – 10000: ______ 15000 – 20000: _____ 25000 and above: ____
3. LIFESTYLE PRACTICES
INSTRUCTION: Place a check (√) in the appropriate column for questions answerable by:
Always - at all times
Sometimes - at certain times
Seldom - almost never
Never - not at any time

A. DIET Always Sometimes Seldom Never

1. Do you eat three times a day?

(Breakfast, Lunch, Dinner)

2. Do you eat foods high in fat? (pork, beef

and canned goods)

3. Do you eat foods high in salt? (dried

foods and canned goods)

4. Do you eat foods high in sugar?

(tsokolate, keyk, candies and ice cream)

5. Do you eat foods high in protein? (lean

meat, fish egg and beans)

6. Do you eat foods high in fiber? (fruits,

vegetables and cereals)

7. Do you drink at least 8 glasses of water

a day?

8. Do you drink carbonated beverages?

(softdrinks)

9. Do you take caffeinated drinks every

day?(coffee)

10. Do you take vitamin supplements

everyday?
B. PYSICAL ACTIVITY/EXERCISE Always Sometimes Seldom Never

1. Do you take a bath every day?

2. Do you exercise every day?

3. Do you exercise at least 30 mins a day?

4. Do you join dance classes

weekly?(zumba, aerobic, taebo)

5. Do you engage in sports/ sports

activities? (basketball, volleyball lawn
tennis, and etc.)

6. Do you exercise during your leisure

time?

7. Do you perform warm up before playing

or having an exercise?

8. Do you have a scheduled workout once

a week?

9. Do you exercise early in the morning?

10. Do you drink water after your exercise?

C. VICES Always Sometimes Seldom Never

1. Do you drink alcoholic beverages every

day?

2. Do you find difficulty in getting the

thought of drinking out of your mind?

3. Do you drink alcoholic beverages during

night for you to sleep?
 4. Is getting drunk more important than
your next meal?

5. Do you smoke / drink alcoholic

beverages even if you are ill?

6. Do you smoke cigarettes?

7. Do you smoke when you wake up in the

morning?

8. Do you find it difficult to refrain from

smoking in places where it is forbidden?

9. Do you engage in gambling activities?

10. Do you go to entertainment houses?

4. Physical Health Status

Instruction: Place an X over the “YES” box to answer yes. If you answer “NO”, make no
mark. For follow questions, place a check (√) in the appropriate column or write down
your answer on the line provided.

Current Health Condition Yes No

1. Did you experience any illness within the last six
months?
If yes, what are the symptoms you have experienced?
______ Fever
______ Cough
______ Colds
______ Difficulty of Breathing
______ Headache
______ Backache
______ Fatigue
______ Numbness of lower extremities
______ Increase blood pressure
______ Others, pls. specify
_________________________________________
2. Did you undergo medical treatment regarding your
illness?
If yes, were you relieved of the symptoms thereafter?
_______________________________________________________________
_______________________________________________________________

If no, what did you do to relieve the symptoms?

_______________________________________________________________
_______________________________________________________________
3. Do you feel basically healthy?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________
4. Do you feel consider yourself happy?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________
5. Do you often feel "older" than you should for your age?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________
6. Do you feel relaxed to do exercise such as walking?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________
7. Do you physically perform leisure activities?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________
8. Do you able to perform the physical task of your work?
If yes, how?
_______________________________________________________________
_______________________________________________________________

If no, why?
_______________________________________________________________
_______________________________________________________________