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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
Have you ever had unprotected sex? Yes No 6. Do you go clubbing/ partys Yes No 8.5. 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 . Do you have any children? Yes No If your answer is yes how many? 7.
Are you Talkative. Do you get pressured by your friends to do things that you don t want to do Yes 13. Do you own a mobile phone? Yes No No . . Do you have friends Yes No 11. 14. Bold Shy Quiet Confident No . Do you suffer from depression ? Yes 15. Do you go out with your friends Yes No 12.10.
o 20.16. Do you want to lose weight? Yes. No . What size clothes do you wear? Size 8-10 12-14 16-18 20+ 18. Are you happy with your life? Yes somtimes No Why? Sometime good things happen and happy when im not in my house 17. Are you happy with your weight Yes N . Are you insecure about your body? Yes Why ? Because sometimes i look at other people and wish i had their body sometimes No 19.
2-3 3 -4 4 -5 25. No If yes what do you hope to acheive Flat stomach Abs Thin thigs . . Do you have a balanced diet? Yes No. Tonned leg. How many stoned do you want to lose 1. Do you go on diets? Yes . No If yes how many times a week 1 2 3 4 5 everyday . How many portions of fruit and vegetables do you eat a day? Tick one 1-2 .21. 24. Tonned Butt Lose weight 22. Do you excercise ? Yes. 2 3 4 23.
Are you allergic to anything? If yes state the name/s belows seafood 29. Are u currently ill yes sore throat and a blocked nose 32.26. Do you have any disabilities no 30. Any inherited conditions no 31. Chronic illneses eczema How stressful is ure life hardl How would u like to improve have a balanced diet . How many times a week do you eat Crisps Chocolate 1 Sweets 0 Cakes 1 Pies 4 Biscuits 4 4 27. How many glasses of water do you drink a day? 1-2 2 -3 3 -4 5 -6 7 -8 . 28.