Healthier Me Programme Questionnaire

In order to assess your eligibility to participate in the Healthier Me programme you must complete this lifestyle questionnaire. The questionnaire is used to learn a bit about yourself so we can inform you about our services and support you in choosing the most suitable option to help you improve and maintain a healthy lifestyle.

    Demographics

    Address and postcode (required)

    Do you pay for your prescriptions? (required)

    Are you pregnant? (required)

    Do you have any disabilities? (required)

    Do you need any reasonable adjustments? e.g. interpreter, partially sighted

    Do you access the internet? (required)

    Which of the follow do you prefer? (please tick all that apply) (required)

    Do you give consent for us to share your answers with other medical professionals? (required)

    Are you on the severe mental illness register? (required)

    Are you on the learning disabilities register? (required)


    BMI - Body Mass Index


    Occupational questions / sedentary questions

    Are you currently: (required)

    If you are employed, please choose your area of work from the list below.

    How long did you spend sitting yesterday? (required)

    Would you say the above is typical of a normal day for you? (required)

    How many hours of screen time did you have yesterday? (Including at home) (required)

    Would you say the above was a typical day for you? (required)


    Lifestyle questions

    In the past week, on how many days did you do a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise, brisk walking or cycling for fun or to get to and from places. It does not include house work or physical activity that is part of your job) (required)

    How many portions of fruit did you have yesterday? (required)

    How many portions of vegetables did you have yesterday? (required)

    Would you say the above days of fruit and vegetable portions are a good example of a typical day for you? (required)

    How much water did you drink yesterday? (required)

    Is your answer above the same as a typical day for you? (required)

    How useful do you find reading food labels? (0 being not at all useful, 10 being very useful) (required)

    Do you currently use any type of tobacco? (this includes shisha, paan and chewing tobacco as well as cigarettes / cigars / pipe) (required)

    If you do use tobacco, how many times do you smoke / use it a day?

    Do any of your family or friends that you normally socialise with use tobacco? (shisha, cigarettes, paan, chewing tobacco) (required)

    Do you currently use e-cigarettes? (required)


    Medical history

    Do you have any of these conditions? (required)

    Does your condition affect your day-to-day life? i.e. working life, family life, social life, physical activity, travel?

    How are you managing your condition?

    Do you have a family history of: (required)

    Has any of your family suffered a heart attack in the last 2+ years? (required)


    Alcohol use

    How often do you have a drink containing alcohol? (required)

    How many units do you drink on a typical day when you are drinking?

    How often have you had 6 or more units (if female), or 8 or more units (if male), on a single occasion in the last year?


    Sleep quality

    How well do you sleep? (Think about how you’ve been sleeping over the past 2 weeks) (required)


    Statements of wellbeing

    Please put your personal response to the following statements:

    I’ve been feeling optimistic about the future (1 being none of the time, 5 being all of the time) (required)

    I’ve been feeling useful (1 being none of the time, 5 being all of the time) (required)

    I’ve been feeling relaxed (1 being none of the time, 5 being all of the time) (required)

    I’ve been dealing with problems well (1 being none of the time, 5 being all of the time) (required)

    I’ve been thinking clearly (1 being none of the time, 5 being all of the time) (required)

    I’ve been feeling close to other people (1 being none of the time, 5 being all of the time) (required)

    I’ve been able to make up my own mind about things (1 being none of the time, 5 being all of the time) (required)