Health Assessment
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
Heart disease kills 10 times more women every year than breast cancer, so it is vitally important to evaluate for heart disease risks. Routine testing, whether blood work or questions, misses 82% of women at risk.
This is a short profile that has been shown to be very effective at assessing your individual risk. Remember, we are not after normal, we are after optimal!
(Please add up your points for each answer and put the total in the box at the bottom of this section)
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.
Your Tobacco Usage
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.
Add up the total number of alcoholic drinks you consume in an average week.
Your Eating Habits
Low-fat foods
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Salad, fruits and vegetables
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Pasta and rice
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Wholegrain breakfast cereals
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Bread
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Lean meat
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Fish
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Eggs
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Low-fat dairy products (incl. skimmed and semi-skimmed milk)
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Low-fat spread
High-fat foods
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Most carry-out and fast foods (pizza, curry, Chinese)
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Ready meals
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Fried foods (incl. fried breakfast)
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Crisps and chips
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Cakes
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muffins and biscuits
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Donuts
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Pasties
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pies and sausage rolls
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Sausages and burgers
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Hard cheese
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butter and mayo
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Regular milk and milk shakes, Chocolate bars
Low-fiber foods
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White bread
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White pasta
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rice and noodles
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Some breakfast cereals (Corn Flakes, Rice Krispies and CoCo Pops)
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Chips and crisps
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Potatoes without the skin
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Ready and microwave meals
High-fiber foods
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Wholegrain and brown bread
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Brown pasta and rice
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Nuts,
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lentils and beans
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Most fruits and vegetables
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Oats
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Wholegrain breakfast cereals (Shredded Wheat, Fruit and Fiber)
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Jacket potatoes
High-salt foods
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Most ready and microwave meals
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Cured, smoked and preserved cold meats
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Many canned soups and foods
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Many carry-out and fast foods (pizza, Chinese, burgers)
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Chips and crisps
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Corn flakes
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Shop-bought bakery products
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White bread
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Ketchup
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Creamy sauces in restaurants
Your Medical Health
Do you regularly have any of the following bodily symptoms?
Please check all of the symptoms that apply to you.
Please check all that apply to you. Include all conditions you know about, even if your relative is now deceased.
Your Stress
Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?
Sleep
Your Work
Your Sexual Health
FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...
Your Safety
You said that you have at some time felt unsafe or threatened:
Your Overall Health & Happiness
Nutrition
(Please include the type if you are currently taking any of the following)
Goals & Readiness
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.