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 □
During a typical week, how many times do you regularly exercise?
1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9+□
What exercise do you take part in?
Do you wear glasses for sport?
Yes □ No □
How do you think a person benefits from exercising?
Yes □ No □ __________________________________________________________________________________________________(State why)
Are you on any type of diet to help improve your weight? E.g. vegetarian
Do you smoke? If yes please state how many cigarettes a day
Yes □ No □ Please State ___________
Do you suffer from any illness?
Yes □ No □ ________ (If yes please mention)
Do you eat five portions of fruit and veg. every day?
Yes □ No □
Do you regularly monitor your weight?
Yes □ No □ ________(If yes, state how often)
Do you drink alcohol? If yes how many units per week (leave blank if you don’t drink)
Yes □ No □
Have you ever been involved in any accidents, if so how were you affected?
Yes □ No □ _________________(If yes please state)
Do you drink tea or coffee, if yes how many cups a day?
Yes □ No □
How many spoons of sugar do you put in your tea or coffee?
0-1 □ 2-3 □ 4-5 □ 6+ □
How many meals do you have in a day?
How many snacks do you have in a day?
What specific diet plan do you follow?
How often do you eat meat?
How do you see yourself in terms of body type: Obese, Fat, Average, Athletic, Slim or Anorexic?
Do you wear glasses or corrective lenses, if so what for, short/long distance?
Do you take any illegal substances, if so which and if not have you ever tried any?
How do you usually get around e.g. car or walk?
How far do you travel to work/ place of study?
_____ Miles
What are your hobbies?
How much time do you spend outdoors?
________ Hours per day
How would you rate your hygiene on a scale of 1 to 10, with 10 being extremely clean, And why?
Can you walk briskly for a mile without getting out of breath?
Yes □ No □
