To fill in the questionnaire;
Read questions carefully and take your time to answer.
Please tick the appropriate boxes.
Respondent
1) What is your gender?
Male Female
2) Into which age category do you fit?
16-20 21-30 31-40 41-50 51-60 60+
3) What is your ethnicity?
White British White Other Black African
Black Other Asian Indian Mixed
Asian Other Chinese Other
Prefer not to say;
(Please Specify) ________________________________________
4) Do you have a disability?
No Yes Prefer not to say Please specify (if yes)
5) What is your Occupation?
6) Weight (Kg): 40-60 61-80 81-100 101-120 121-140 141-160 161+
7) Height (m): m
Health and ill health
8) Describe in your opinion what being healthy is?
___________________________________________________________
___________________________________________________________
__________________________________________________________
9) Which best describes your concept of health?
Being healthy means the absence of illness,
Disease and mental distress
Being healthy is due to the right maintenance
E.g. regular exercise and a balanced diet
Being healthy is caused by a balance
of emotional, physical, intellectual
and social elements of your life
10) How would you describe your current health on a scale of 1-10; 1 being poor and 10 being excellent?
11) How would you describe your current health?
I don’t eat well enough or do enough exercise
I feel ok with my diet and exercise
I feel good about myself; making sure
I eat right and maintain exercise
I feel very healthy; I do plenty of exercise
and eat a balanced diet
12) Which of the following statements best describes your concept of ill health?
If I feel ill then I assume I am ill
I’m ill when I a doctor diagnoses
that I have an infection etc
If my body occurs a breakdown of normal
Functioning health then I am ill
Exercise
13) During a typical week, how many times do you regularly exercise?
0 1 2 3 4 5 6 7 7+
14) What exercise do you take part in?
15) Do you attend exercise classes such as the gym?
Yes No
16) How do you think a person benefits from exercising?
17) Do you consider the amount of exercise you do to affect your daily lifestyle?
Monitoring weight
18) Do you think that your daily lifestyle affects your health and weight?
Yes No I don’t consider my daily routine to affect my health
19) From looking at the chart above is your BMI suitable (body mass index comparing weight along height)?
Yes No
20) Do you regularly monitor your weight?
Yes No
21) Why do you monitor your weight?
22) Are you on any type of diet to help improve your weight?
Yes No
Smoking
23) Do you smoke? (If no move on to question 26 )
Yes No
24) Why did you take up smoking and carry on with it now?
25) If you smoke cigarettes how many do you smoke a day?
1-10 11-20 21-30 31-40 40+
26) What effect does smoking have on health?
27) How do you feel when people smoke around you?
28) Are you happy with the government’s ban of smoking in public places?
Yes No
29) Why do you think this?
30) Do you think smoking is associated with alcohol consumption?
Very strongly Strongly Occasionally Hardly Not at all
