Health Assessment

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
ASIAN OR ASIAN AMERICAN
MIXED RACE
SPANISH, HISPANIC OR LATINO
BLACK OR AFRICAN AMERICAN
OTHER ETHNIC / RACIAL GROUP
RACE & ETHNIC GROUP
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
Do you smoke or use chewing tobacco?
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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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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Do you drink alcohol?
Add up the total number of alcoholic drinks you consume in an average week.
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Your Eating Habits
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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

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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

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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

How often do you eat sweet, sugary foods in a typical day?
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On a typical day how many servings of fruits and vegetables do you eat?
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Your Medical Health
Which of the following medical conditions have you been diagnosed with?
Which of the following preventive and screening services have you had?
Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

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

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

Your Stress
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How are you coping with the stress and pressure in your life? (Please check ONE answer only.)
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Here is a list of common symptoms of anxiety. How much has each one bothered you during the past week, including today?
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Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?
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