SELF HEALTH ASSESSMENT QUESTIONNAIRE

 

 

 General

Age: ______years                                                                                                                                           Height (estimate): ________cms

Sex: Male Female                                                                                                                                Weight (estimate): ________kgs

Smoking

  1. Do you smoke?

 Yes No (go to question 2)

1a. How keen are you to stop smoking? (please circle)

0 = not keen at all / 7 = very keen

0 1 2 3 4 5 6 7

1b. When you wake up each day, how soon do you smoke your first cigarette?

 More than 60 minutes

 31-60 minutes

 5-30 minutes

 Less than 5 minutes

1c. How many cigarettes do you smoke on a typical day?

 10 or less

 11 – 20

 21 – 30

 More than 30

Nutrition

  • 1 serve of fruit = medium sized apple/orange/banana or 2 apricots/kiwi fruit or ½ cup tinned fruit
  • 1 serve of vegetables = ½ cup cooked vegetables or 1 cup salad vegetables
  1. How many serves of vegetables (including fresh, frozen and tinned vegetables) do you usually eat each day?

One serve or less

Two serves

Three serves

Four serves

Five serves

Six or more serves

Don’t eat vegetables

  1. How many serves of fruit (including fresh, frozen and tinned fruit) do you usually eat each day?

One serve or less

Two serves

Three or more serves

Don’t eat fruit

  1. How many days of the week do you usually eat junk foods that are high in fat, salt or sugar (such as deep fried foods, hot chips, pies, pastries, chocolates, lollies, etc)?
  • None
  • One day

Two days

Three days

Four days

Five days

Six days

Seven days

  1. During working hours, how many days of the week do you usually eat junk foods that are high in fat, salt or sugar (such as deep fried foods, hot chips, pies pastries, chocolates, lollies, etc)?
  • None
  • One day

Two days

Three days

Four days

Five days

Six days

Seven days

  1. Why do you usually choose fast food instead of something you prepared yourself? (Please tick all that apply)

 I never eat/drink fast foo

Cheaper

 More convenient

 Tastes better/good

 Availability

The hours I work

 Makes me feel better when I am stressed

 I don’t know how to prepare healthy meals to take to work

Access to vending machines

 I cannot be bothered to bring something healthy from home

Lack of access to kitchen/food preparation facilities

Hydration

  1. On average, during your normal working day, how many glasses (250 ml) of fluid (water, cordial, soft drink, juice, milk, coffee, tea) do you consume? (Please circle one)

1 2 3 4 5 6 7 8+

  1. On average, during your normal working day, how many glasses (250 ml) of plain drinking water do you consume? (Please circle one)

1 2 3 4 5 6 7 8+

Alcohol

1 standard drink is equivalent to

  • 375 ml mid-strength beer (3.5% alcohol by volume)
  • 100 ml red wine (13% alcohol by volume)
  • 30 ml high-strength spirits (40% alcohol by volume)
  1. Do you drink alcohol at all?

 Yes No (go to question 13)

  1. How many days of the week do you drink?

 1-4 days

 5-7 days

  1. How many standard drinks do you have on a typical day when you are drinking?

 1-2

 3 or more

  1. On any single occasion do you ever consume 5 or more standard drinks?

 Yes No

Physical Activity

  1. How many times a week do you usually do:
  1. 20 minutes or more of vigorous-intensity physical activity that makes you sweat or puff and pant (for example, heavy lifting, digging or jogging)?

0 1 2 3 4 5 6 7+ times

Two 10-minute sessions count as one 20-minute session.

  1. 30 minutes or more of walking (for example, walking from place to place for exercise or recreation)?

0 1 2 3 4 5 6 7+ times

Three 10-minute sessions (or two 15-minute sessions) count as one 30-minute session.

  1. 30 minutes or more of other moderate-intensity physical activity that increases your heart rate or makes you breathe harder than normal (for example, carrying light loads, slow cycling)?

0 1 2 3 4 5 6 7+ times

Three 10-minute sessions (or two 15-minute sessions) count as one 30-minute session.

  1. How much of your total activity occurs in work time? (Work time does include travelling to and from work.)

 None

Some

 Most

 All

  1. Please indicate reasons why you are NOT more physically active (tick all that apply).

 Too tired

 Not enough time

 Lack of facilities

 Shift work, especially nights or overtime

Out on the road most of the time

Not encouraged to

No shower facilities

Not motivated

 Not enough flexible time in work hours

Health issues

I am already active enough

Wellbeing

  1. The next ten questions are about how you have been feeling in the past four weeks.

None of the time

A little of the time

Some of the time

Most of the time

All of the time

In the past four weeks, about how often did you feel tired for no good reason?
In the past four weeks, about how often did you feel nervous?
In the past four weeks, about how often did you feel so nervous that nothing could calm you down?
In the past four weeks, about how often did you feel hopeless?
In the past four weeks, about how often did you feel restless or fidgety?
In the past four weeks, about how often did you feel so restless you could not sit still?
In the past four weeks, about how often did you feel depressed?
In the past four weeks, about how often did you feel that everything was an effort?
In the past four weeks, about how often did you feel so sad that nothing could cheer you up?
In the past four weeks, about how often did you feel worthless?

 

Time Spent Sitting

  1. Please estimate the number of hours that you spend at your workplace on a typical day. (Please circle)

0 1 2 3 4 5 6 7 8 9 more than 9

  1. Please estimate the number of hours that you spend sitting at your workplace, including during meal and snack breaks, on a typical day. (Please circle)

0 1 2 3 4 5 6 7 8 9 more than 9

  1. How many times, on a typical day while at your workplace, do you interrupt your sitting, e.g. by standing up, walking somewhere or getting a drink?
  • 5 times or less
  • 6-10 times
  • 11-20 times
  • More than 20 times

Section 2

Needs Assessment Survey

  1. Which of the following would you most like included in your health and wellbeing program? Please tick all that apply.
  • Bicycle or walk/run related activities
  • Exercise/physical  regularsessions
  • Fatigue management information sessions
  • Financial planning support
  • Flu vaccinations
  • Health assessments – ‘face-to-face’
  • Health assessments – ‘online’
  • Health coaching to address physical activity or nutrition issues
  • Healthy food options available (e.g. fruit bowls, vending machines, canteens)
  • Information seminars/workshops
  • Injury prevention/rehabilitation services
  • Lunch/break room
  • Activities that promote good mental health
  • Organisation sport team(s)
  • Pedometer event or walking challenge
  • Personal development opportunities for life skills
  • Shower and change facilities
  • Smoking cessation programs (e.g. Quit smoking program)
  • Sports/activity days
  • Stress management programs and strategies
  • Stretching sessions
  • Storage areas (e.g. bike storage, lockers)
  • Subsidised membership to off-site facilities/programs
  • ‘Walk and talk’ or active meetings
  • Website with health and wellbeing information
  • Workplace massage
  1. When would you prefer these activities to occur?
  • Before work
  • During lunch time
  • After work
  • At weekends
  1. How often would you attend health and wellbeing activity (if offered this frequently)?
  • Every day
  • A few times a week
  • Once a week
  • A few times a month
  • Once a month
  • Less than once a month
  1. What factors would stop you from participating in health and wellbeing activities?
  • Not enough time
  • Not motivated
  • Too expensive
  • Not interested
  • Out on the road/away from the worksite or office most of the time
  • Other (please specify)
  1. What other health and wellbeing initiatives would you like to see implemented at your life?
    ______________________________________________________________________________________

PLEASE, BRING THIS SELF ASSESSMENT TO YOUR DOCTOR APPOINTMENT.

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CONTACT

 

Phone: +61 (0) 408 875 490

Business Hours: Tue, Fri 9 am -5.30 pm. Sat 9-12

Address: 4/433, South Road, Bentleigh 3204 VIC Australia