Your doctor would like to be able to help you maintain and improve your health. Please complete the following questionnaire and present it to your doctor.

1. Please tick your current main interests.

Family

Relationships

Paid Work

Study Work

Unpaid Work

Personal well being

Sport and recreation activites ............................................................................................................

Hobbies and leisure activities .............................................................................................................

2. Please tick the good things about how 'fit and well' you are.

Have lots of energy

Sleep well

Always eat breakfast

Good cholesterol level

No 'pot belly'

Active (3 x wk/ 30mins)

3. Are you concerned about the influence of the following factors on your health?

Smoking

Drinking

Loneliness

Eating habits

Weight

Work environment

Lack of Exercise

Stress

Family problems

4. Do you smoke?

Yes >> please go to Q. 4a

No

Q4a. Do you wish to quit?

ex smoker

Yes No

Undecided

5. How often do you engage in exercise or activity (eg., brisk walking long enough to work up a light sweat (at least 30 minutes)?

3 or more times a week

seldom

1-2 times per week

never

7. Have you been getting sufficient sleep lately?

Yes

No

Don't know

8. Have you ever had a cholesterol test?

Yes

No            Don't know      Date: ……………

9. Have you had a tetanus injection in the past 10 years?

Yes

No            Don't know      Date: ……………

Name:___________________________________ Date:______________________