World Health Survey Template Page 13
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574000. RISK FACTORS
Time Begin: __ __ : __ __
..
Tobacco
(Show Tobacco list to respondent ----see Appendix A4.1)
.
Q4000 Do you currently smoke any tobacco products such as cigarettes, cigars,
1. Daily
2. Yes, but not daily
5. No, not at all
If 2 or No: Go to
or pipes?
Q4010
Q4001 For how many years are you smoking daily?
_____________________
.
On average, how many of the following products do you smoke each day?
.
Q4002 Manufactured cigarettes
_____________________
Q4003 Hand-rolled cigarette
_____________________
Q4004 Pipefuls of tobacco
_____________________
Q4005 Other:
_____________________
.
Alcohol
..
(Show Alcohol card to respondent ----see Appendix A4.2)
.
Q4010 Have you ever consumed a drink that contains alcohol (such as beer,
1. Yes
5. Never
If Never: Go to
wine, etc.)?
Q4020
.
During the past 7 days, how many standard drinks of any alcoholic beverage did you have each day?
.
Q4011 Monday
_____________________
Q4012 Tuesday
_____________________
Q4013 Wednesday
_____________________
Q4014 Thursday
_____________________
Q4015 Friday
_____________________
Q4016 Saturday
_____________________
Q4017 Sunday
_____________________
WORLD HEALTH SURVEY - RISK FACTORS
4.1
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