Total Health Assessment - Questionnaire

Your Title

First Name

Your Street Number/PO Box

Your Suburb

Total Health Assessment Questionnaire

The questionnaire below is only a sample for demonstration purposes. Any answers provided will not be processed for the generation of a personal report.

Your Email

Work Contact Number		Home Contact Number
Mobile Contact Number		Preferred Contact Number

Best Days to be Contacted	Any day	OR	Monday Tuesday Wednesday Thursday Friday
Best Times to be Contacted	Any time	OR	9-12pm 12-5pm 5-8pm

Complete each question as best you can, by indicating the best response.

Your results will be kept strictly confidential.

Be sure to click the [Continue] button at the bottom of this page, even if you wish to finish this questionnaire later. Your answers may then be held until your return up to 92 days later.

1 SECURE ID Confirmed

SEX

Male
Female

DATE OF BIRTH

Day: Month: Year:

HEIGHT (without shoes)

centimetres

feet inches

WEIGHT (without shoes)

6	What was your latest blood pressure reading?	Systolic (high number) Diastolic (low number)
	If you do not know the numbers, which best describes your blood pressure?
	Has your doctor prescribed medicine for high blood pressure?

7	What was your latest total cholesterol level? (based on a blood test)	mmol/L
	If you do not know the number, which best describes your cholesterol?

What is your HDL cholesterol level? (based on a blood test)

mmol/L
I'm not sure

HEALTH-RELATED BEHAVIOURS

CIGARETTE SMOKING
How would you describe your cigarette smoking habits?

Still smoke, Go to question 10
Used to smoke, Go to question 11
Never smoked, Go to question 12

STILL SMOKE

cigarettes per day

Go to question 12

11	USED TO SMOKE How many years has it been since you smoked cigarettes on a fairly regular basis?	years
	What was the average number of cigarettes per day that you smoked in the 2 years before you quit?

Do you smoke or use

pipes?
cigars?
smokeless tobacco?

How often do you use prescribed drugs or over-the-counter medication which affect your mood or help you to relax?

How many drinks of alcoholic beverages do you have in a typical week?
(one drink = one can or stubby of regular beer, glass of wine, shot of spirits (45 ml) or can of pre-mixed spirits)

drinks

How many times in the last month did you drive or were a passenger in a vehicle when the driver had perhaps too much to drink?

times last month

16	In the next 12 months, how many kilometres will you probably drive or be a passenger in each of the following? A. Car, truck or van
	B. Motorcycle

What percent of the time do you usually buckle your seat belt when driving or a passenger?

On the average, how close to the speed limit do you usually drive?

On a typical day, how do you usually travel?

How many servings of fresh or frozen fruits and vegetables do you eat on a typical day?
(eg 1 Serve = 1 piece of fruit, 1/2 a cup of cooked vegetables, 1 cup of raw vegetables)

How often do you eat fast food?

In the average week, how many times do you engage in moderate-intensity physical activity for at least 30 minutes? Examples include things such as a brisk walk or cycling.

QUALITY-OF-LIFE INDICATORS

In general, how satisfied are you with your life? (include personal and professional aspects)

Would you agree you are satisfied with your job?

In general, how strong are your social ties with your family and/or friends?

Considering your age, how would you describe your overall physical health?

How many hours of sleep do you usually get at night?

Have you suffered a personal loss or misfortune in the past year? (for example: a job loss, disability, divorce, separation, gaol term, or the death of someone close to you)

How often do you feel tense, anxious, or depressed?

During the past year, how much effect has stress had on your health?

In the past year, how many days of personal illness have you had that kept you from your normal activities?

MEDICAL HISTORY AND SELF-CARE

Do you have a family history (brother, sister, mother, father, grandparents) of:

High blood pressure
Heart problems

Diabetes
Cancer
High cholesterol

Have you had:

Heart problems
Diabetes
Cancer
Chronic bronchitis/emphysema

Past stroke
Asthma
Arthritis
Allergies
Back pain

34	When was the last time you had these preventive services or health screenings?	Faecal occult blood test Flu shot Tetanus shot Blood pressure check Cholesterol check Check for skin cancer by a doctor or nurse
	for Women Only	Pap test Mammogram Breast exam by a doctor or nurse
	for Men Only	Digital rectal exam for your prostate

In the past 12 months, how many times have you:

Visited a doctor's office or clinic as a patient
Gone to the hospital emergency department (Casualty) for treatment
Stayed overnight in a hospital as a patient
Used a toll-free number for medical advice
Used a self-care book
Been treated with alternative medicine

Women (Men go to question 37)

How many women in your natural family (mother and sisters only) have had breast cancer?

PERSONAL INFORMATION

Current marital status

In which country were you born?

Are you of Aboriginal or Torres Strait Islander origin?

What is the highest level of education you have completed?

HEALTH PLANNING QUESTIONS

Have you made any of these changes to enhance your health during the past 12 months?

Increased physical activity
Lost weight
Reduced alcohol use
Quit or cut down smoking
Reduced fat/cholesterol intake
Lowered blood pressure
Lowered cholesterol level
Coped better with stress

Are you planning to make any changes to keep yourself healthy or improve your health in the next 6 months?

Increase physical activity
Lose weight
Reduce alcohol use
Quit or cut down smoking
Reduce fat/cholesterol intake
Lower blood pressure
Lower cholesterol level
Cope better with stress

Be sure to click the [Continue] button at the bottom of this page, even if you wish to finish this questionnaire later. Your answers may then be held until your return up to 92 days later.

Dec 1, 2011; 2:18:06 GMT

Problems: problems@www.hmrc.kines.umich.edu