Lifestyle questionnaire

Date: …………………….
Full name: …………………………………………………
Date of birth: ……………………………………………
Gender: ……………………………………………………
Weight: ……………………………………………………
Hight: ………………………………………………………
Mobile number:
Address: ……….……………………………………………
………….……………………………………………………….
…………………………………………………………………..
Doctor’s name and address: ……………………………………………
…………………………………………………………………………………………
Are you pregnant?
What is your status: a) student b) employed c) unemployed
Where do you study/work?
What is your current health status?
Have you had any injures in past?
Does someone in your family suffers from a chronic disease?

1. Do you drink alcohol? If yes, please move on to question 1.2 and 1.3. 1.2. How often do you drink alcohol? 2.3 How many units: a) per day, b) per week.

1. Do you smoke cigarettes? If yes, please move on to question 1.2, if not please move on to question 2. 2.2 How many cigarettes: a) per day, b) per week. 2. Does anyone smoke in your family? 3. Are you a passive smoker? YES/NO

1. Is your lifestyle stressful? 2. Have you been under stress recently? 3. How do you recognize stress in your life? 4. How does stress affect you? 5. When you are stressful, how do you feel physically? a) Do you feel tired during the day? b) Can you sleep well at night? c) Does your stomach hurt? 6. How do you feel emotionally? a) Nervous or worried about stressful situations, b) You get angry easily. 7. Do you have good relation with your family/partner? 8. Is your work/college stressful? 9. Is your time well managed? 10. Do you use any kind of relaxation? 11. How much do you sleep?

1. What is your physical level? 2. Do you meet physical recommendation? 3. How often do you do any sport/exercise? a) Never, b) Less than