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Questionnaire - Unit 2

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Introduction

1. Name: 2. Date of birth (DD/MM/YYYY): 3. Sex 4. Height: 5. Weight: 6. Body mass index: 7. What type of accommodation do you live in? Flat ( ) Terraced House ( ) Semi Detached House ( ) Detached House ( ) Other ( ) 8. How many people in household: 9. What area you live in: 10. Do you live in a: Town: ( ) City: ( ) Village: ( ) Suburb: ( ) Other (please state): 11. Are you close to local amenities? : Yes: ( ) No: ( ) 12. Do you like where you live? : Yes ( ) No ( ) 13. What would you say are the positive and negative factors about your area? : 14. What is your current employment status? : Employed [including self employed] ( ) Not employed ( ) Retired ( ) 15. Do you work? : Full time: ( ) Part time: ( ) 16. Which sector of work are you/were you employed in [If selected employed or retired above]: 17. Do you consider your job to have any risk factors? ...read more.

Middle

: Heavy smoker ( ) Medium smoker ( ) Light smoker ( ) Occasional smoker ( ) Social smoker ( ) Other (Please state): 29. Are you aware of STI's (Sexually transmitted infections (Sexually transmitted diseases) STD's and there affects? : Yes ( ) No ( ) The recommended units per week are: Male - 21 units Female 18 units 1 unit = 1 glass of wine/ Half a pint of larger/1 measure of spirit 30. Do you drink? : Yes ( ) No ( ) 31. If so what do you usually drink? : 32. Do you regularly exceed your recommended amount of alcohol? : Yes ( ) No ( ) 33. Would you consider yourself to have a healthy/balanced diet? : Yes ( ) No ( ) 34. Do you generally have your 5 fruit and vegetables a day? : Yes ( ) No ( ) 35. Do you take any dietary supplements? : Yes ( ) No ( ) If so what: 36. Do you have high cholesterol? : Yes ( ) No ( ) 37. Do you have a high blood pressure? : 38. Do you have a high salt intake? ...read more.

Conclusion

: * * * * 53. How many times a week do you generally socialise? : 54. Do you enjoy being with friends and family? : Yes ( ) No ( ) 55. Do you have any hobbies, if so what are they? : * * * * 56. Would you say you have at least one good support relationship in your life? : Yes ( ) No ( ) 57. How would you rate your social life? : Poor ( ) Average ( ) Good ( ) Excellent ( ) 58. What is your relationship status? : Single ( ) Married ( ) Divorced ( ) Separated ( ) With a partner ( ) 59. Do you have any children? Yes ( ) No ( ) 60. If you have children, what are their ages? 61. On a scale of 1-10 how would you rate your mental health? 62. Do you go for regular check up's at the dentist? : 63. Do you brush your teeth daily, if so how many times? : 64. How many times a week do you have a bath or shower? 65. Is there anything you would like to change about your health and lifestyle to improve it in any way? ...read more.

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