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Health and Wellbeing Questionnaire: 1. Gender

The health and wellbeing questionnaire collects information from individuals about their lifestyle, health status, and wellbeing. It asks for demographic information and seeks to understand behaviors related to relationships, substance use, diet, exercise, stress levels, medical conditions, and goals for a healthier lifestyle. The questionnaire is intended to help assess an individual's overall health and identify any areas that could benefit from improvement.

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esthermad
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137 views6 pages

Health and Wellbeing Questionnaire: 1. Gender

The health and wellbeing questionnaire collects information from individuals about their lifestyle, health status, and wellbeing. It asks for demographic information and seeks to understand behaviors related to relationships, substance use, diet, exercise, stress levels, medical conditions, and goals for a healthier lifestyle. The questionnaire is intended to help assess an individual's overall health and identify any areas that could benefit from improvement.

Uploaded by

esthermad
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Health and Wellbeing Questionnaire

The purpose of this questionnaire is to assess the health and well being of an individual.
Please answer the questions truthfully; it would benefit me a lot if you could answer all the
questions.

Please enter your Name in The box below; all information given is strictly confidential.

1. Gender

Male

Female

2. What age group are you in?

Under 15

16- 24

24-49

50-64

65 & over

3. What is your Martial Status? Tick one

Married

Cohabiting

Single

Divorced

In a Relationship

4. Are you sexually active?

Yes No
5. Have you ever had unprotected sex?

Yes No

6. Do you have any children?

Yes No

If your answer is yes how many?

7. Do you go clubbing/ partys

Yes No

8. Do you do drugs/ ever done drugs?

Yes No

If yes what type/types of drug? ___________________________________

Do you smoke?

Yes No

9. Do you drink alchol?

Yes No

If yes have you ever been drunk

Yes No

If yes how many times have you been drunk?

1-2 2-3 4-5 6+0


10. Do you have friends

Yes No

11. Do you go out with your friends

Yes No

12. Do you get pressured by your friends to do things that you don’t want to do

Yes No.

13. Do you own a mobile phone?

Yes No

14. Do you suffer from depression ?

Yes No .

15. Are you

Talkative.

Bold

Shy

Quiet

Confident
16. Are you happy with your life?

Yes somtimes No

Why?
Sometime good things happen and happy when im not in my house

17. What size clothes do you wear?

Size 8-10 12-14 16-18 20+

18. Are you insecure about your body?

Yes sometimes No

Why ?

Because sometimes i look at other people and wish i had their body

19. Are you happy with your weight

Yes N.o

20. Do you want to lose weight?

Yes. No

21. Do you go on diets?


Yes . No

If yes what do you hope to acheive

Flat stomach

Abs

Thin thigs .

Tonned leg.

Tonned Butt

Lose weight

22. How many stoned do you want to lose

1. 2 3 4

23. Do you excercise ?

Yes. No

If yes how many times a week

1 2 3 4 5 everyday.

24. How many portions of fruit and vegetables do you eat a day? Tick one

1-2 . 2-3 3-4 4-5

25. Do you have a balanced diet?

Yes

No.

26. How many times a week do you eat


Crisps 4

Chocolate 1

Sweets 0

Cakes 1

Pies 4

Biscuits 4

27. How many glasses of water do you drink a day?

1-2 2-3 3-4 5-6 7-8 .

28. Are you allergic to anything? If yes state the name/s belows

seafood

29. Do you have any disabilities no

30. Any inherited conditions no

31. Are u currently ill yes sore throat and a blocked nose

32. Chronic illneses eczema

How stressful is ure life hardl


How would u like to improve have a balanced diet

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