Annual health review

Section

Exercise

1. Physical activity at work

Please tell us the type and amount of physical activity involved in your work, tick the box that is most relevant to you:

I am not in employment (retired, retired for health reasons, unemployed, full-time carer etc)

I spend most of my time at work sitting (office work etc)

I spend most of my time at working standing/walking, it does not include intense physical effort (Shop assistant, hairdresser, security guard etc)

My work involves definite physical effort including handling of heavy objects/use of tools (plumber, electrician, cleaner, nurse)

My work involves vigorous physical activity (scaffolder, refuse collector, personal trainer)

2. Physical Exercise

During the last week, how many hours approximately did you spend on each of the following activites? Please state amount in each box:

Physical exercise (swimming, jogging, aerobics, football, tennis, gym workout etc):

Cycling, including cycling to work and during leisure time:

Walking, including walking to work, shopping and for pleasure:

Housework/Childcare:

Gardening/DIY:

Diet

How would you say you diet is from Good, Average, or Poor?

Good Diet (3 meals a day, including 5 servings of fruits and vegatables, plenty of water)

Average

Poor (mainly consistening of fast foods, no fruit or vegetables, and no water)

Smoking

Do you currently smoke tobacco?

Yes

No

Have you ever smoked?

Yes

No

Do you currently smoke an e-cigeratte/vape?

Yes

No

Alcohol Screening

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Additional alcohol consumption questions

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

No

Yes, but not in the last year

Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

No