Healthy Lifestyle Questions

Please fill out all the questions on the form then click on the SUBMIT button when you are done.
You can go back to make any changes you want until you SUBMIT - clicking on the RESET button will erase all your answers.

First Name: Last Name:

Social Security Number (or other ID Number):

Age:

Sex: Male Female

Personal Health Questions

How often do you eat chips, fried foods, red meats, cheese made from cream or whole milk, egg yoks, other high fat foots or combinations dishes made from these foods?
click on one of the followinge

How often do you eat foods which are high in fiber? Foods such as beans, whole grains, cereals, fruits and vegetables, are high in fiber?
click on one of the following

In an average week, how many times do you engage in physical activity (exercise or work which lasts at least 20 minutes without stopping and which is hard enough to make you breathe more heavily and your heart beat faster)?
click on one of the following

Have you ever had any of the following?
click on Yes, No or Not Sure for each choice

Asthma:	Yes No Not Sure
Diabetes:	No Not Sure
Heart Disease:	Yes No Not Sure
Cancer:	Yes No Not Sure

In general, how satisfied are you with your life?
click one choice
Mostly Satisfied Partly Satisfied Not Satisfied

Have you ever been told that you have high blood pressure?
click on one choice

How would you describe your overall physical health?
click on one choice

Tobacco Use

In a day, how many times do you:
click on Yes, No or Not Sure for each choice

Smoke cigars:	None 1 or less 2 or more
Smoke a pipe:	None 1 or less 2 or more
Use Smokeless Tobacco:	None 1 or less 2 or more

Do you smoke cigarettes?:
choose one Never Smoked Used to smoke Still Smoke now
Cigarettes Now:
Years quit:
Cigarettes before quit:

Traveling

In the next 12 months, how many thousands of miles will you probabyly travel by each of the following (the US average is 10,000 miles per year):
Car, truck or van miles: ,000
Motorcycle miles: ,000

If you ride a motorcycle, how often you wear a helmet?
click on one of the following

When you traavel in motor vehicle, it is USUALLY a:
click on one of the following

What percent of the time do you usually buckle your saafety belt when driving or riding?
click on one of the following

On the average, how close to the speed limit do you usally drive?
click on one of the following

For Women Only

How old were you when your first child was born?
click on one of the following

Are you currently pregnant?
click on Yes, No or Not Sure
Yes No Not Sure

How many women in your natural family (mother and sisters only) have had breast cancer??
click on one of the following

Have you had a hysterectomy (Removal of your uterus)?
click on Yes, No or Not Sure
Yes No Not Sure

How often do you examine your breasts for lumps?

When did you last have your breasts examined by a physician or nurse?
click on one of the following

When did you last have a breast Xray (Mammogram)?
click on one of the following

When did you last have a pap smear?
click on one of the following

When did you last have a rectal exam?
click on one of the following

For Men Only

When did you last have a rectal or prostate exam?

How often do you examine your testicles for lumps?

Emotional Well Being

click on Yes, No or Not Sure for each choice
In the past year, have you had two weeks or more during which you felt sad, blue or depressed; or when you lost all interest or pleasure in things that you usually cared about or enjoyed?	Yes No Not Sure
Have you had 2 years of more in your life when you felt depressed or sad most days even you felt okay sometimes?	Yes No Not Sure
Have you felt depressed or sad much of the time in the past year?	Yes No Not Sure

In the past year, how much effect has stress had on your life?
Choose one of the following

States of Change

Are you interested in making a change in the following areas:

	click on Yes or No for each choice
Alchohol Use:	Yes No
Diet and Nutrition:	Yes No
Exercise:	Yes No
Stress:	Yes No
Tobacco use:	Yes No
Weight management:	Yes No

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Concert Health Resources LTD
Post Office Box 403, Kaukauna, Wisconsin 54130
Phone: 920-766-7015 800-275-8744 Fax: 920-766-0385