Yes ( )
No ( )
If so please state what:
18. Do you enjoy your job the majority of the time? :
Yes ( )
No ( )
19. Do you feel you have adequate finances? :
Yes ( )
No ( )
20. What are the main stress factors in your life? :
Money ( )
Family ( )
Health ( )
Work ( )
Other:
21. If so how do these factors affect you? :
22. Do you have any medical health problems? :
Yes ( )
No ( )
If yes please state:
23. Do you take any recreational or prescription drugs? :
Yes ( )
No ( )
If yes please state:
24. Do you currently take/have ever taken any recreational drugs? :
Yes ( )
No ( )
If yes please state:
25. Do you feel this has affected your health in a positive or negative way? :
Positive ( )
Negative ( )
26. Do you smoke?
Yes ( )
No ( )
27. If yes what do you smoke? (For example cigarettes/cigars):
28. Would you class your self as a? :
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? :
39. Do you have a high fat intake? :
40. Do you eat a lot of red meat (Steak, pork, lamb ECT)
41. Do you think your diet contributes to any positive or negative factors in your lifestyle? :
42. Are you happy with your weight? :
Yes ( )
No ( )
43. How would you rate yourself? :
Overweight ( )
Underweight ( )
Average ( )
44. Have you ever been on any diets? :
If so which? (If so please describe)
45. How would you rate your self esteem? :
High ( )
Low ( )
Other [Comments]:
46. Do you take part in regular exercise? :
Yes ( )
No ( )
47. How many hours of exercise do you do per week on average? :
48. What type of exercise do you do? :
49. Do you feel exercise helps your health and well being? :
50. Do you feel you get enough sleep? :
Yes ( )
No ( )
51. Do you sleep during the day? :
Yes ( )
No ( )
Occasionally ( )
52. What do you generally do in your leisure time? :
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?
