This personal health self-evaluation is something that I use during my introduction to health (health triangle) lesson. This can also be used at the end of a class as a post-class assessment to see if health habits have improved throughout the class/year/semester.
Self assessment is a skill expected to be carried by high school students, as seen in the following skill standard from The Guidance Document for Achieving the New York State Standards in Health Education:
SM.C.1 Conducts a personal
assessment of health and safety
knowledge and skills
Clear directions are provided directly on the worksheet and a Spanish version is included.