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HealthQuestionnaire
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About You
Email/Id
age
Height(cm or ft'in)
Weight(kg or lb)
What is your occupation ?
Number of hours you spend working every day on average
0
/ 14
Do you sit for long hours while working ?
Do you work in place with natural light ?
Diet
Percent of meat consumption in your average daily diet.
0
/ 100
Percent of seafood consumption in your average daily diet.
0
/ 100
Percent of fruit and vegetable consumption in your average daily diet
0
/ 100
Do you regularly drink sweet fizzy drinks ?
Do you regularly add salt to meals at the table ?
Do you drink plenty of fluids at regular intervals during the working day ?
Do you regularly eat cakes, sweets, chocolate or biscuits at work?
How many caffeinated drinks (e.g. tea, coffee) do you consume per day?
0
/ 10
Sleep
Do you have kids ?
Do you sleep in shared bed ?
On average how long does it take you to fall asleep (in minutes)?
When you are in bed awake, what do you think about?
Trying to fall asleep
Family matters
Work / college / school
Other
If other, please add some comment
Do you do anything in bed to help you to get to sleep such as?
Relaxation exercises
Counting
Lying still
Reading
Watching TV
Listening to radio
Using ear plugs
Other
If other, please add some comment
How often do you have trouble getting off to sleep?
Less than once a month
About once a month
Two to four times a month
Many times a week
Daily
Do you get annoyed / angry when you cannot sleep?
How long do you think other people of your age sleep for each night (in hours) ?
Stress
Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Not at all
Several days
More days than not
Nearly everyday
Over the past 2 weeks, how often have you felt little interest or pleasure in doing things?
Not at all
Several days
More days than not
Nearly everyday
Do you smoke cigarettes?
Do you vape?
If yes, how many average per day
How many days on average do you consume alcohol per month?
Do you take other substances (e.g. Cannabis)?
If yes, how many times per day
Other
If there is some other info e.g. health condition or allergies or something else you want to share, please add here
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