Abstract Background In many parts of the world, including in China, extreme heat events or heat waves are likely to increase in intensity, frequency, and duration in light of climate change in the next decades. Risk perception and adaptation behaviors are two important components in reducing the health impacts of heat waves, but little is known about their relationships in China. This study aimed to examine the associations between risk perception to heat waves, adaptation behaviors, and heatstroke among the public in Guangdong province, China. Methods A total of 2,183 adult participants were selected using a four-stage sampling method in Guangdong province. From September to November of 2010 each subject was interviewed at home by a well-trained investigator using a structured questionnaire. The information collected included socio-demographic characteristics, risk perception and spontaneous adaptation behaviors during heat wave periods, and heatstroke experience in the last year. Chi-square tests and unconditional logistic regression models were employed to analyze the data. Results This study found that 14.8%, 65.3% and 19.9% of participants perceived heat waves as a low, moderate or high health risk, respectively. About 99.1% participants employed at least one spontaneous adaptation behavior, and 26.2%, 51.2% and 22.6% respondents employed <4, 4–7, and >7 adaptation behaviors during heat waves, respectively. Individuals with moderate (OR=2.93, 95% CI: 1.38-6.22) or high (OR=10.58, 95% CI: 4.74-23.63) risk perception experienced more heatstroke in the past year than others. Drinking more water and wearing light clothes in urban areas, while decreasing activity as well as wearing light clothes in rural areas were negatively associated with heatstroke. Individuals with high risk perception and employing <4 adaptation behaviors during heat waves had the highest risks of heatstroke (OR=47.46, 95% CI: 12.82-175.73). Conclusions There is a large room for improving health risk perception and adaptation capacity to heat waves among the public of Guangdong province. People with higher risk perception and fewer adaptation behaviors during heat waves may be more vulnerable to heat waves.