LIFESTYLE QUESTIONNAIRE
Name: Date:
1. Physical activity (9)
Healthy exercise or physical activity usually involves activity that lasts for at least 20
minutes, raises your pulse and produces hard breathing. For example: running, cycling
or sport.
How often do you take part in this type of exercise –
Daily []
3 times weekly []
Once weekly []
Once monthly []
Extremely rarely/never [ ]
I cannot take exercise because of disability [ ]
If you do exercise, how long are your workouts?
15 – 30 mins []
30 – 45 mins []
45 – 60 mins []
60 mins + []
-If you don’t take part in exercise, what is this the reason behind this?
- Have you ever done any structured exercise in the past?
- If so, what was it?
- How long did you stick with it?
, - Did you get the results you wanted from it?
- If you did stop, why did you stop?
- What types of physical activities do you enjoy doing the most/least?
2. Smoking (5)
Do you smoke? Yes [ ] No [ ]
If yes, do you –
Smoke less than 1 cigarette/day []
1-9 cigarettes/day []
10-19 cigarettes/day []
20-39 cigarettes/day []
More than 40 cigarettes/day []
Smoke a pipe [ ]
Smoke cigars [ ]
If No, have you –
Never ever smoked []
Given up smoking in the last year []
Not smoked for more than 1 year []
3. Stress (7)
Would you say that stress effects your daily life?
On a scale of 1-10, 1 (being no stress) and 10 (being high stress), how much stress would
you say that you experience on a daily basis in your work/personal life?
Do you know what factors in your life cause your stress, if so please rank the top three
contributors?
Name: Date:
1. Physical activity (9)
Healthy exercise or physical activity usually involves activity that lasts for at least 20
minutes, raises your pulse and produces hard breathing. For example: running, cycling
or sport.
How often do you take part in this type of exercise –
Daily []
3 times weekly []
Once weekly []
Once monthly []
Extremely rarely/never [ ]
I cannot take exercise because of disability [ ]
If you do exercise, how long are your workouts?
15 – 30 mins []
30 – 45 mins []
45 – 60 mins []
60 mins + []
-If you don’t take part in exercise, what is this the reason behind this?
- Have you ever done any structured exercise in the past?
- If so, what was it?
- How long did you stick with it?
, - Did you get the results you wanted from it?
- If you did stop, why did you stop?
- What types of physical activities do you enjoy doing the most/least?
2. Smoking (5)
Do you smoke? Yes [ ] No [ ]
If yes, do you –
Smoke less than 1 cigarette/day []
1-9 cigarettes/day []
10-19 cigarettes/day []
20-39 cigarettes/day []
More than 40 cigarettes/day []
Smoke a pipe [ ]
Smoke cigars [ ]
If No, have you –
Never ever smoked []
Given up smoking in the last year []
Not smoked for more than 1 year []
3. Stress (7)
Would you say that stress effects your daily life?
On a scale of 1-10, 1 (being no stress) and 10 (being high stress), how much stress would
you say that you experience on a daily basis in your work/personal life?
Do you know what factors in your life cause your stress, if so please rank the top three
contributors?
