Health And Fitness Assessment Questionnaire (Vitality) (Page 2 of 4) in pdf

SECTION 3. HEALTH HABITS

3.1.

Smoking Status: Please tick the appropriate box relating to your smoking

Never smoked

1 - 5 years

11 - 15 years

less than 3 months

How long have you been an ex-smoker?

less than 1 year

6 - 10 years

more than 15 years

Current smoker

< 10 per day

10 - 20 per day

21 - 30 per day

> 30 per day

Cigar

Cigarettes

Pipe

Chewing Tobacco

For Smokers only:

Please tick only one of the options that best describe your current smoking situation

I have no intention of becoming tobacco free in the next 6 months.

I intend to become tobacco free in the next 6 months.

I am trying to become tobacco free, but I am not always successful.

Although I am currently using tobacco again, in the past I have been tobacco free for more than 3 months.

Non Smoking

I confirm that I am a non-smoker and that:

1. I do not smoke and have not smoked any tobacco products, regularly or occasionally, within the last 3 months.

2. I agree to inform my insurers within 3 months of commencing smoking. I also agree to the reversal of any points that may have been awarded for being a

non-smoker, if they are awarded within the same calendar year in which I commenced smoking.

3. I agree to undergo an u-cotine test to prove my non-smoker status should my insurer request one. I understand that such requests are made randomly.

Please sign here to accept this declaration.

3.2.

Alcohol Use

Please make the appropriate selection relating to your weekly alcohol consumption

consumption.

I don't have any alcoholic drinks

Never more than 1 - 2 drinks per occasion or per day.

3 - 4 drinks in a day, only 2 - 3 per month.

3 - 4 drinks in a day, 4 times per month

3 or more drinks in a day, more than once a week and / or more than 4 drinks at a time.

3.3.

Sleep: Please make the appropriate selection relating to your sleeping pattern.

Undisturbed sleep

Disturbed sleeping pattern, 3-4 nights per week

Disturbed sleeping pattern, 1-2 nights per week

Disturbed sleeping pattern, 5-7 nights per week

In general, I wake up:

Refreshed

Unrefreshed

3.4

Stress Management

Are you coping with your daily stress?

No, and I have no intention to implement coping strategies in the next 6 months.

No, but I intend to learn how to cope with my daily stress in the next 6 months.

I am trying to cope but I do not always cope successfully.

Yes, I have been coping with my daily stress, but for LESS than 6 months.

Yes, I have been coping with my daily stress for MORE than 6 months.

Although I am not coping well with my daily stress, in the past I have coped well for more than 3 months.

3.5

Dietary Assessment

Think about your eating habits over the past year or so. Approximately how often do you eat each of the following foods? Tick one box for each

food.

Never/Once or

2-3 times

1-2 times

3-4 times

less than once

5+times per

Meat/Snack

per month

per week

week

Hamburgers or cheeseburgers

Red meat, e.g. beef and mutton

Fried chicken (with skin)

Hot dogs, frankfurters, salami, Russians, sausages

Cold meats, e.g. polony, cheese / olive loaf, beef (+ fat), etc.

Salad dressing, mayonnaise

Margarine or butter

Eggs

Bacon or pork sausage

Cheese or cheese spread

Full-cream milk

Potato chips ("slap chips")

Potato crisps, corn chips, popcorn, etc

Ice cream

Doughnuts, cake, cookies, puddings, etc

Health And Fitness Assessment Questionnaire (Vitality) Page 2

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