Health Assessment

First Name

Last Name

Age

What is your height?

What is your current weight?

What is your waist circumference?

Please note: If you are female and pregnant, enter your pre-pregnancy weight.

Enter the waist measurement of the most recent pair of pants that you have bought. If you don’t know your waist circumference, you can leave this blank.

About You

How would you best describe your race and ethnic group?
We’d like to know about your racial and ethnic origins. The reason for this is that some diseases and
illnesses are more common in people with certain backgrounds. Please check ONE answer only

WHITE

White American

Other White Background

MIXED RACE

SPANISH, HISPANIC OR LATINO

Mexican, Mexican American, Chicano

Puerto Rican

Cuban

Other Spanish, Hispanic or Latino origin

BLACK OR AFRICAN AMERICAN

African

Caribbean

Other Black Background

RACE & ETHNIC GROUP

I prefer not to answer this

Your Physical Activity

Think about a typical 7-day week. How much of the following exercise do you get?
Please write the number of days of exercise and the average time (in minutes) spent exercising.

Vigorous physical activities (Like heavy lifting, digging, aerobics or fast cycling)

Moderate physical activities (Like carrying light loads, cycling at regular pace or doubles tennis)

Walking for at least 10 minutes (Includes walking at work, home or for any exercise or leisure)

Your Tobacco Usage

Do you smoke or use chewing tobacco?

Yes, I currently smoke

No, I gave up less than 10 years ago

No, I gave up more than 10 years ago

No, I’ve never smoked or chewed tobacco (if you select this answer, skip the next question)

Which of the following tobacco products do you/did you use?

Please write how much tobacco you used or currently use and how long you have used it.

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In a single day, how many cigarettes do you/did you smoke?

How many years have you smoked cigarettes?

Your Drinking Habits

How many of the following non-alcoholic drinks do you usually consume in a typical day? Please write the number of each type of drink you consume in the boxes below.

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Number of cups of coffee

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Number of cans of soda

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Number of cans of energy drinks

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Number of cups of milk?

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Number of cups of juice?

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Number of cups of tea

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Number of cans of diet soda

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Number of cups of water?

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Number of milkshakes?

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Number of cups of hot chocolate?

Do you drink alcohol?

Yes

No (if you select this answer, skip the next question)

Only very occasionally, less than one drink a week (if you select this answer, skip the next question)

Add up the total number of alcoholic drinks you consume in an average week.

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Glasses of Beer (12oz)?

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Glasses of White Wine (5oz)?

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Glasses of Red Wine (5oz)?

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Number of Mixed Drinks (1.5oz)?

Your Eating Habits

When choosing foods, do you tend to eat high-fat or low-fat items? (1 = Low fat foods, 5= High fat foods)

Low-fat foods

Salad, fruits and vegetables
Pasta and rice
Wholegrain breakfast cereals
Bread
Lean meat
Fish
Eggs
Low-fat dairy products (incl. skimmed and semi-skimmed milk)
Low-fat spread

High-fat foods

Most carry-out and fast foods (pizza, curry, Chinese)
Ready meals
Fried foods (incl. fried breakfast)
Crisps and chips
Cakes
muffins and biscuits
Donuts
Pasties
pies and sausage rolls
Sausages and burgers
Hard cheese
butter and mayo
Regular milk and milk shakes, Chocolate bars

When choosing foods, do you tend to eat high-fiber or low-fiber items? (1=Low fiber foods, 5= High fiber foods)

Low-fiber foods

White bread
White pasta
rice and noodles
Some breakfast cereals (Corn Flakes, Rice Krispies and CoCo Pops)
Chips and crisps
Potatoes without the skin
Ready and microwave meals

High-fiber foods

Wholegrain and brown bread
Brown pasta and rice
Nuts,
lentils and beans
Most fruits and vegetables
Oats
Wholegrain breakfast cereals (Shredded Wheat, Fruit and Fiber)
Jacket potatoes

When choosing foods, do you tend to eat high-salt or low-salt items? (1=Low salt, 5= High salt)

Low-salt foods

Fruits and vegetables
Grilled chicken
Grilled fish
Plain pasta
Unsalted nuts
Eggs
Mozzarella and most soft cheeses

High-salt foods

Most ready and microwave meals
Cured, smoked and preserved cold meats
Many canned soups and foods
Many carry-out and fast foods (pizza, Chinese, burgers)
Chips and crisps
Corn flakes
Shop-bought bakery products
White bread
Ketchup
Creamy sauces in restaurants

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Your Medical Health

Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

UROGENITAL

Frequent Need to Pass Urine (including at night)

Incontinence

Burning or Stinging on Passing Urine

Blood in Urine

THORAX

Shortness of Breath

Palpitations (fast-beating heart)

Cough

Chest Tightness

Which of the following conditions have affected your immediate biological family (your father, mother, sisters and/or brothers)?

Bowel cancer

Breast Cancer

Ovarian Cancer

Heart Disease (only if it started before the age of 65 years in a female relative)

Heart Disease (only if it started below the age of 55 years in a male relative)

Please check all that apply to you. Include all conditions you know about, even if your relative is now deceased.

Your Stress

Thinking about your life, on average how stressed and under pressure do you feel? Try to think about all areas of your life, including your work life, home life and family life, before you answer the question. (1=Low stress, 5= High stress)

How are you coping with the stress and pressure in your life? (Please check ONE answer only.)

Looking back over the last 3 months, how often have you felt anxious or nervous for no good reason? (1= not at all, 5= all the time)

Here is a list of common symptoms of anxiety. How much has each one bothered you during the past week, including today?

Numbness and tingling

Wobbliness of legs

Feeling hot

Unable to relax

Fear of the worst happening

Dizzy or lightheaded

Heart pounding or racing

Terrified

Unsteady

Nervous

Feelings of choking

Hands trembling

Shaky

Fear of losing control

Difficulty breathing

Scared

Fear of dying

Indigestion or discomfort in abdomen (stomach)

Faint

Face flushed

Sweating (not due to heat)

Looking back over the last 3 months, how often have you felt sad, miserable or depressed? (1=not all all, 5= all the time)

Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?

Have you been feeling sad or down in the dumps?

Does the future look hopeless?

Do you feel worthless or think of yourself as a failure?

Do you feel inadequate or inferior to others?

Do you get self-critical and blame yourself for everything?

Do you have trouble making up your mind about things?

Have you been feeling resentful and angry a good deal of the time?

Have you lost interest in your career, your hobbies, your family or your friends?

Do you feel overwhelmed and have to push yourself hard to do things?

Do you think you’re looking old or unattractive?

Have you lost your appetite, or do you overeat or binge compulsively?

Do you suffer from insomnia and find it hard to get a good night’s sleep? Or are you excessively tired and sleeping toomuch?

Have you lost your interest in sex?

Do you worry a great deal about your health?

Do you have thoughts that life is not worth living or think that you might be better off dead?

How would you describe the support you are able to get from other people during times of stress? Think about people who are close to you and you know will help and listen when times are tough (1=I have no support, 5= I have plenty of support)

Have you had regular bodily pain over the last month?

Please check one answer to rate your pain in all the body areas below.

Head

Neck

Shoulders

Chest

Abdomen

Elbows

Hands and Wrists

Hips

Knees

Feet and Ankles

Back

Sleep

How many hours of sleep do you get on atypical weekday/work-night?

How many hours of sleep do you get on atypical weekend/non-work night?

How often do you find you have difficulty falling asleep or difficulty staying asleep at night?

I have these problems most nights

I have these problems at least 2 or 3 times a week

I have these problems about once a week

I occasionally have these problems, but less than once a week

I virtually never have these sort of problems

On a regular week day when you wake up in the morning and have gotten yourself out of bed and ready for the day ahead, how rested and refreshed do you feel?

Your Work

Your Sexual Health

Are you satisfied with your sex life?

FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...

Are you satisfied with your level of sexual desire or interest?

Are you satisfied with your level of lubrication during sexual activity or intercourse?

Do you experience discomfort or pain during sexual activity or intercourse?

Your Safety

When you are driving or riding in a car, do you wear a seat belt?

Never

Sometimes

Most times

Always

Do you feel or have you ever felt unsafe or threatened in your home environment or relationships?

Yes

No (if you select this answer, please skip the following question)

You said that you have at some time felt unsafe or threatened:

Have you ever been in a relationship where you have you been physically harmed or threatened with physical violence?

Yes

Are your friends or family aware of this situation?

Yes

Do you have a safe place to go and the resources you need in an emergency?

Yes

Do you feel safe in all of your current relationships?

Yes

Your Overall Health & Happiness

In general, taking all things into account, how would you rate your satisfaction and happiness with your life?

Excellent

Not Good

Terrible

Making Changes

How important is it to make changes to your lifestyle to improve your health? (1= Very important, 5= Not important)

How ready are you to start making these changes? (1=Note ready, 5= Very ready)

How confident are you that you’ll succeed? (1= Not confident, 5= Very confident)

Nutrition
(Please include the type if you are currently taking any of the following)

Multi-vitamins

Single Vitamins (Vitamin C, E, etc)

Calcium

Herbs

Food Allergies/ Intolerances

Other

Goals & Readiness

I want to lose weight because:

My nutrition-related goals are:

If I could change 3 things about my health & nutritional habits, they would be:

The biggest challenge(s) to reaching my nutrition/weight loss goals are:

I have fallen in the last 6 months.

Yes

I use or have been advised to use a cane or walker to get around safely.

Yes

Sometimes I feel unsteady when I am walking.

Yes

I steady myself by holding onto furniture when I walk.

Yes

I am worried about falling.

Yes

I need to push with my hands to stand up from a chair

Yes

I am often dizzy when I first stand up.

Yes

I have trouble stepping up onto a curb.

Yes

I often have to rush to the toilet.

Yes

I have lost some feeling or have pain in my feet.

Yes

I take medicine that sometimes makes me feel light-headed or more tired than usual.

Yes

I take medicine to help me sleep or improve my mood

Yes

I often feel sad or depressed.

Yes

. Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

. Poor appetite or overeating

Feeling bad about yourself or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Place an X in the corresponding space for each situation.

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theatre or a meeting)

A passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Anxiety Inventory

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by each symptom during the PAST WEEK, INCLUDING TODAY.

Numbness or tingling