Healthier Me Programme Questionnaire

In order to assess your eligibility to participate in the Healthier Me programme you must complete this lifestyle questionnaire. The questionnaire is used to learn a bit about yourself so we can inform you about our services and support you in choosing the most suitable option to help you improve and maintain a healthy lifestyle.

Demographics

Name (required)

Your email (required)

Date of birth (required)

Telephone / mobile number (required)

Please provide your ethnicity below or leave blank if you would prefer not to say.

Do you pay for your prescriptions? (required)
YesNo

Are you pregnant? (required)
YesNoNot applicable

Do you have any disabilities? (required)
YesNo

Do you need any reasonable adjustments? e.g. interpreter, partially sighted

Do you access the internet? (required)
YesNo

Which of the follow do you prefer? (please tick all that apply) (required)
Online servicesTelephoneVideo callFace to face

Do you give consent for us to share your answers with other medical professionals? (required)
YesNo

BMI - Body Mass Index

What is your height? (cm) (required)

What is your weight? (kg) (required)

Occupational questions / sedentary questions

Are you currently: (required)
Employed/self employedNot workingRetiredA student

If you are employed, please choose your area of work from the list below.
Health and care servicesRetailHospitalityTransport & securityOffice workEducation or early years settingManufacturingOutdoor non-constructionConstruction and manualTradespersonOther occupation (please provide in box below)

Other occupation:

How long did you spend sitting yesterday? (required)
Less than 4 hoursBetween 4-6 hoursBetween 6-8 hoursMore than 8 hours

Would you say the above is typical of a normal day for you? (required)
YesNo

How many hours of screen time did you have yesterday? (Including at home) (required)
Less than 4 hoursBetween 4-6 hoursBetween 6-8 hoursMore than 8 hours

Would you say the above was a typical day for you? (required)
YesNo

Lifestyle questions

In the past week, on how many days did you do a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise, brisk walking or cycling for fun or to get to and from places. It does not include house work or physical activity that is part of your job) (required)
Only 1 day1+ days2+ days3+ days4+ days5+ days

How many portions of fruit did you have yesterday? (required)
1-2 portions2-3 portions3-4 portions5+ portions

How many portions of vegetables did you have yesterday? (required)
1-2 portions3-4 portions5+ portions

Would you say the above days of fruit and vegetable portions are a good example of a typical day for you? (required)
YesNo

How much water did you drink yesterday? (required)
Less than 6 cups or glasses6-8 cups or glasses a dayMore than 8 cups or glasses a day

Is your answer above the same as a typical day for you? (required)
YesNo

How useful do you find reading food labels? (0 being not at all useful, 10 being very useful) (required)
012345678910

Do you currently use any type of tobacco? (this includes shisha, paan and chewing tobacco as well as cigarettes / cigars / pipe) (required)
YesNo

If you do use tobacco, how many times do you smoke / use it a day?
Less than 5 times5-10 times10-20 timesMore than 20 times

Do any of your family or friends that you normally socialise with use tobacco? (shisha, cigarettes, paan, chewing tobacco) (required)
YesNo

Do you currently use e-cigarettes? (required)
YesNo

Medical history

Do you have any of these conditions? (required)
Diabetes (Type 1 or 2)High blood pressureHigh cholesterolHeart conditionRespiratory conditionAny other medical condition

Does your condition affect your day-to-day life? i.e. working life, family life, social life, physical activity, travel?
YesNo

How are you managing your condition?

Do you have a family history of: (required)
Heart disease or heart conditionType 2 DiabetesHigh blood pressureHigh cholesterolNone of the conditions listed above

Has any of your family suffered a heart attack in the last 2+ years? (required)
YesNo

Alcohol use

How often do you have a drink containing alcohol? (required)
NeverMonthly or less2-4 times per month2-3 times per week4 times or more per week

How many units do you drink on a typical day when you are drinking?
0-23-45-67-810 or more

How often have you had 6 or more units (if female), or 8 or more units (if male), on a single occasion in the last year?
NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Sleep quality

How well do you sleep? (Think about how you’ve been sleeping over the past 2 weeks) (required)
Always sleep wellHave the odd bad nightMore good nights than badMore bad nights than goodSleep badly most of the timeExtremely sleep deprived

Statements of wellbeing

Please put your personal response to the following statements:

I’ve been feeling optimistic about the future (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been feeling useful (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been feeling relaxed (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been dealing with problems well (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been thinking clearly (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been feeling close to other people (1 being none of the time, 5 being all of the time) (required)
12345

I’ve been able to make up my own mind about things (1 being none of the time, 5 being all of the time) (required)
12345