Wellness Profile - Questionnaire

Size: px

Start display at page:

Download "Wellness Profile - Questionnaire"

Lauren Potter
7 years ago
Views:

1 G1. G2. Of all the possible actions you could take in order to prevent disease and maintain/enhance your health, how much do you estimate you are currently doing? 1. 0% (none at all) 2. 25% 3. 50% 4. 75% % (all possible) Which area of behavior would you most like to change in order to improve your health? 1. Exercise 2. Nutrition 3. Weight Management 4. Alcohol 5. Tobacco (smoking) 6. Stress Management EX1. Considering your time both at work and outside of work, how many days a week do you get 10 or more minutes of continuous aerobic activity like brisk walking (3-4 mph), sweeping floors, mowing a lawn, digging dirt, running, swimming, or bicycling? 5. 5 or more days a week If you answered 'None' to question EX1, go to question EX10. EX2. While doing your job, how many days a week do you work continuously for at least 10 minutes at a time doing vigorous aerobic activities like lifting and carrying heavy items, shoveling sand, or digging ditches by hand? 5. 5 days a week If you answered 'None' to question EX2, go to question EX4. 1 of 7

2 EX3. On average, how many total minutes a day are you doing these job-related, vigorous aerobic activities? Only count the time you are continuously active for 10 or more minutes per activity session. EX4. Again, while doing your job, how many days a week do you work continuously for at least 10 minutes at a time doing moderate-intensity aerobic activities like brisk walking (3-4 mph), mowing lawns, vacuuming floors, or carpentry work? 5. 5 days a week If you answered 'None' to question EX4, go to question EX6. EX5. On average, how many total minutes a day are you doing these job-related, moderate aerobic activities? Remember, only count the time you are continuously active for 10 or more minutes per activity session. EX6. Now think about your activities outside of work. How many days a week do you engage in at least 10 minutes of vigorous aerobic activities like running or fast bicycling where you are continuously moving and breathing deeper and faster than normal? 5. 5 or more days a week If you answered 'None' to question EX6, go to question EX8. 2 of 7

lawns, vacuuming floors, or carpentry work? 5. 5 days a week If you answered 'None' to question EX4, go to question EX6. EX5.

3 EX7. On average, how many total minutes a day are you doing these outside-of-work, vigorous aerobic activities? Only count the time you are continuously active for 10 or more minutes per activity session. EX8. Again, looking only at your activities outside of work, how many days a week do you engage in at least 10 minutes of continuous, moderate-intensity aerobic activities like brisk walking (3-4 mph), vacuuming floors, or playing golf without a cart? 5. 5 or more days a week If you answered 'None' to question EX8, go to question EX10. EX9. On average, how many total minutes a day are you doing these outside-of-work, moderate aerobic activities? Remember, only count the time you are continuously active for 10 or more minutes per activity session. EX10. Considering your time both at work and outside of work, are you regularly doing activities that maintain or increase the strength of the muscles in your arms, shoulders, chest, back, abdomen, and legs? 1. No 2. Yes, some of these muscle groups 3. Yes, all of these muscle groups If you answered 'No' to question EX10, go to question NU1. EX11. How many days a week are you doing these muscle-enhancing activities? 1. Less than 1 day a week 2. 1 day a week 3. 2 or more days a week 3 of 7

Again, looking only at your activities outside of work, how many days a week do you engage in at least 10 minutes of continuous, moderate-intensity aerobic activities like brisk walking (3-4 mph),

4 NU1. NU2. NU3. NU4. NU5. NU6. NU7. How often do you eat breakfast? 3. Most of the time 4. Always On average, how many servings of foods which are high in calcium do you eat each day? Foods such as milk, cheese, yogurt and green leafy vegetables are high in calcium. 1. Less than 1 serving each day servings each day 3. 3 or more servings each day On average, how many servings of foods which are high in fiber do you eat each day? Foods such as beans, whole grains, cereals, fruits and vegetables are high in fiber. 1. Less than 1 serving each day servings each day servings each day 4. 5 or more servings each day On average, how many servings of foods which are high in fat do you eat each day? Foods such as whole milk, cheese, eggs, red meat, fried foods and some desserts are high in fat. 1. Less than 1 serving each day servings each day servings each day 4. 5 or more servings each day How often do you choose low fat or low cholesterol foods? How often do you add salt to your cooking or add it to your food at the table? How often do you read nutrition labels on food packages? 4 of 7

3 or more servings each day On average, how many servings of foods which are high in fiber do you eat each day? Foods such as beans, whole grains, cereals, fruits and vegetables are high in fiber. 1.

5 NU8. On average, how many drinks of alcoholic beverages do you have in a week? A drink is a 12 oz. bottle or can of beer, a 5 oz. glass of wine, a 12 oz. wine cooler, or a shot of liquor. 1. Less than 1 drink/week drinks/week drinks/week 4. More than 14 drinks/week If you answered 'Less than 1 drink/week' to question NU8, go to question SF1. NU9. NU10. SF1. SF2. SF3. SF4. On average, how many drinks do you have in one setting? drinks/setting drinks/setting 3. More than 5 drinks/setting On average, how many days per week do you drink alcohol? 1. Less than 1 day/week days/week days/week days/week How many times in the last month did you ride in a car when the driver was under the influence of drugs or alcohol? 1. None 2. One or more times What percent of the time do you buckle your safety belt when riding in a car? -- 0% 2. Seldom % 3. Sometimes % 4. Nearly always % 5. Always % How would you describe your driving behavior? 1. Safe and deliberate 2. Sometimes take chances 3. Aggressive How often do you wear sunscreen or protective clothing when you are in the sun? 4. Always 5 of 7

On average, how many drinks do you have in one setting? 1. 1-2 drinks/setting 2. 3-5 drinks/setting 3. More than 5 drinks/setting On average, how many days per week do you drink alcohol? 1. Less than 1 day/week 2.

6 SF5. SF6. SF7. TB1. TB2. When riding a bicycle, motorcycle, or similar vehicle, how often do you wear a helmet? 4. Always 5. Don't ride such a vehicle Does your home have a smoke detector that works? When lifting objects, even when they are not very heavy, do you lift them properly? What is your exposure to second-hand smoke? 1. None 2. A little 3. A lot Do you use cigars, pipes, or smokeless tobacco such as chewing tobacco, snuff or pouches? TB3. Do you smoke cigarettes? 1. Currently smoke 2. Used to smoke 3. Never smoked If you answered 'Used to smoke' or 'Never smoked' to question TB3, go to question ST1. TB4. ST1. What is the primary reason you have not quit smoking? 1. Can not break the addiction 2. Too much stress in my life 3. Enjoy smoking 4. Afraid to gain weight During the past year, how much effect has stress had on your health? 1. None t much 3. A lot 6 of 7

A lot Do you use cigars, pipes, or smokeless tobacco such as chewing tobacco, snuff or pouches? TB3. Do you smoke cigarettes? 1. Currently smoke 2. Used to smoke 3.

7 ST2. ST3. ST4. ST5. ST6. ST7. ST8. ST9. ST10. Do you think your current level of stress is high enough to affect your health or quality of life? How effective do you think you are in dealing with the stress in your life? 1. Not effective 2. Somewhat effective 3. Effective 4. Not sure Do your sleep patterns promote good health? How often do you feel tense, anxious or upset? In general, do you have emotional support from others to help you deal with stress? How often do friends or relatives suggest that you should slow down, take life easier or relax more? How often do you find yourself getting irritated or annoyed with others? How often do you feel a chronic sense of struggle with daily events? Have you suffered a personal loss or misfortune in the past year that had a serious impact on your life?, 1 loss/misfortune 2. Yes, 2 or more losses/misfortunes 3. No 7 of 7

How often do you feel tense, anxious or upset? In general, do you have emotional support from others to help you deal with stress?

Part B News 1. BEHAVIORAL RISK FACTORS HEALTH RISK ASSESSMENT (HRA) TEMPLATE FOR USE WITH ANNUAL WELLNESS VISITS

Part B News 1. BEHAVIORAL RISK FACTORS HEALTH RISK ASSESSMENT (HRA) TEMPLATE FOR USE WITH ANNUAL WELLNESS VISITS 1. BEHAVIORAL RISK FACTORS PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do you usually exercise? minutes per