Health Questionnaire:
Contact Details:
Title: Mr
Name: Ben Eades DOB: 09/02/06 Gender: Male
Mobile: 07518923184
Email:
Home Address: 7 Nugent Street, Sheffield
Emergency Contact - 07979566511
Title: How do you know this person: Father
Name: David Eades DOB: 26/03/83 Gender: Male
Mobile: 07979566511
Email:
Alcohol Consumption: Tick the one appropriate to you.
How many alcoholic beverages do you consume a week?
_____________________ - never - 1-5- x 6-10- 11/upwards-
Smoking: Tick the one that applies to you.
Do you smoke? never
Daily - Occasionally - Never - x
If yes, which category do you fall under:
, 1- 3 per day 4-7 8-11 - Above
Daily Diet:
How many calories do you consume per day when completing a daily counter on
myfitnesspal app?
____________________________ 1600
On a typical day, what is your diet for the following:
Breakfast - Fruit
Lunch- Sandwich
Dinner- Varies throughout the week
How much fruit and vegetables do you consume in a day?
________________________ or 1-2- x 3-4- 5+
How many litres of water do you drink a day? 1.5-3l
500ml-1l x 1.5-3l- 3.5l+
Physical activity levels:
Do you complete 30 minutes of moderate intensity exercise per day? yes
Yes- x No -
If yes, how many hours per week do you exercise? 4 to 6 hours
Contact Details:
Title: Mr
Name: Ben Eades DOB: 09/02/06 Gender: Male
Mobile: 07518923184
Email:
Home Address: 7 Nugent Street, Sheffield
Emergency Contact - 07979566511
Title: How do you know this person: Father
Name: David Eades DOB: 26/03/83 Gender: Male
Mobile: 07979566511
Email:
Alcohol Consumption: Tick the one appropriate to you.
How many alcoholic beverages do you consume a week?
_____________________ - never - 1-5- x 6-10- 11/upwards-
Smoking: Tick the one that applies to you.
Do you smoke? never
Daily - Occasionally - Never - x
If yes, which category do you fall under:
, 1- 3 per day 4-7 8-11 - Above
Daily Diet:
How many calories do you consume per day when completing a daily counter on
myfitnesspal app?
____________________________ 1600
On a typical day, what is your diet for the following:
Breakfast - Fruit
Lunch- Sandwich
Dinner- Varies throughout the week
How much fruit and vegetables do you consume in a day?
________________________ or 1-2- x 3-4- 5+
How many litres of water do you drink a day? 1.5-3l
500ml-1l x 1.5-3l- 3.5l+
Physical activity levels:
Do you complete 30 minutes of moderate intensity exercise per day? yes
Yes- x No -
If yes, how many hours per week do you exercise? 4 to 6 hours
