HEALTH & LIFESTYLE QUESTIONAIRE
FOR COMPLETION BY EMPLOYEE:
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PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING
1. I declare that all the following statements are true to the best of my knowledge. I accept that in the event that subsequently it is revealed that the medical information has not been disclosed by me, or has been misleading or false, that the medical report will be considered invalid.
2. I understand that I may be required to attend for consultation and physical examination.
3. I understand that although this form will be treated in medical confidence, I have agreed to release any such information to my employer for the purpose of health planning. |
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Signature: ……………………………… Date: ……………………………. |
1. Personal Details:
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Name:
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Telephone:
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Telephone:
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Are you suffering from, or have your ever suffered from, any of the following
(if YES is answered to any of the questions, please give details of treatment and/or medication in the space on page 4):-
Circle the number that best describes your answer.
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Do you have: a. Heart disease of any kind b. High blood pressure c. Asthma, (shortness of breath) d. Chest diseases e. Persistent Cough f. Unexplained weight loss g. Indigestion h. Frequent diarrhoea or constipation i. Any form of bowel disease j. Jaundice, gall bladder or liver disease k. Hernia l. Kidney disease or stones m. Tropical disease n. Back pain or disorder o. Neck pain or disorder p. Rheumatism or arthritis q. Epilepsy or flicker epilepsy r. Mental health problems
s. Stress at home or work t. Eye disease or eye infection u. Deafness of ear v. Skin disease, eczema, psoriasis w. Allergic conditions x. Diabetes y. Blood disorder, anaemia, or haemophilia z. Any form of cancer aa. Any condition requiring surgery bb. Any work related medical condition cc. Bladder, prostrate, Testicular problems (males) dd. Irregular/painful periods (females) ee. severe headaches/migraine
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Yes / No
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2. Infectious Diseases History:
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Have you ever had any of the following diseases?
a. Chicken Pox b. Shingles c. Tuberculosis d. Hepatitis A/B/C e. Food Poisoning
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Yes / No
Yes / No
Yes / No
Yes / No
Yes / No Yes / No
Yes / No
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Further information: Use this area to give further details from the previous questions and details of any other health conditions that you are suffering from or have suffered from in the past.
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3. Vaccination History:
Circle the number that best describes your answer.
(if YES is answered to any of the questions, please give the date of vaccination at the right column)
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Have you had: a. Triple vaccine (in childhood) b. Tetanus c. Hepatitis B d. Hepatitis B post vaccination blood test (Provide report if possible)
e. Rubella f. Others (give details) |
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
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Dates (If Yes):
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4. Physical Activity:
Q1. In the last seven days, on how many days have you engaged in moderate intensity activity, such as brisk walking or tai chi, for a total of 30 minutes or more? ________________
Q2. In the last seven days, how many times have you engaged in vigorous intensity activity such as jogging, lane swimming or playing soccer for 20 minutes or more? ________________
Q3. Which physical activity do you most frequently participate in?
_______________________________________________________________
Q4. Is there any physical activity that you would be particularly interested in taking up?
1. Yes
2. No
If YES, what activity?
_______________________________________________________________
5. Dietary Practices:
Q5. How many servings of fruit do you consume on an average day? ________________
(Please note that 1 serving is equivalent to:
1 medium apple, pear, orange, mango or banana
I wedge of pineapple, papaya, watermelon or honeydew
6 rambutans, dukus, lychees
10 grapes or logans
4 small seeds of durian or jackfruit)
Q6. How many servings of vegetables do you consume on an average day?
________________
(Please note that 1 serving = three quarters of a cup of cooked vegetables)
Circle the number that best describes your answer.
Q7. What type of bread do you usually eat?
1. White/white enriched
2. Wholemeal/high fibre
3. A mixture of white/wholemeal
4. Do not eat bread
Q8. What type of milk or milk based drinks do you usually drink?
1. Whole milk/full fat
2. Low fat
3. Skimmed/non-fat
4. Sweetened condensed milk
5. I don’t drink milk or milk based drinks
Q9. When you eat meat or poultry, how much of the fat and skin do you remove?
1. All
2. Some
3. None
4. I don’t eat meat or poultry
Q10. What kind of oil do you usually use for cooking at home?
1. Butter, dripping, ghee, lard or any other animal fat
2. Hard margarine, vegetable oil, blended oil, palm oil or coconut oil
3. Soft margarine, corn oil, soya bean oil, sunflower oil or safflower oil
4. Peanut oil, canola oil, olive oil
5. Other
6. I don’t cook at home at all
Q11. At the table, when do you usually add salt or sauces to your food?
1. Before tasting food
2. When the food is not tasty enough
3. I don’t add salt or sauces to my food at the table
6. Cigarette Smoking:
Q12. Do you smoke?
1. Daily
2. Occasionally
3. Never [+ Section E, question 18]
Q13. Do you intend to quit smoking?
1. Yes
2. No
7. Alcohol Intake:
Q14. On how many days have you drunk alcohol during the past week?
_______________
Q15. During the past month, have you drunk more than 5 drinks in any one
drinking session?
1. Yes
2. No
If YES, how many times? ______________
8. Health Screening:
Q16. When was the last time you had a basic health screening (e.g. including tests for high blood pressure, diabetes, high blood cholesterol and obesity)?
1. Less than 2 years ago
2. More than 2 years ago
3. Never had any health screening
FOR MALE RESPONDENTS, PLEASE GO TO SECTION G, QUESTION 25.
FOR FEMALE RESPONDENTS ONLY
Q17. When was the last time you had a PAP smear test?
1. Less than 3 years ago
2. More than 3 years ago
3. Never
Q18. Have you been taught breast self-examination by a doctor or nurse?
1. Yes
2. No
Q19. How often do you perform breast self-examination on yourself?
1. Once a month
2. Once every few months
3. Less frequently or never
Q20. How long has it been since you had a mammography?
1. Less than 1 year ago
2. 1 to 2 years ago
3. More than 2 years ago
4. Never
9. Stress & Sleep:
Q25. How many hours do you usually sleep in a 24 hour period?
__________ hours
Q26. How often do you have trouble sleeping?
2. Once a week or less
3. Never
Q27. How would you rate your current level of stress?
On a scale of 1 to 5, where 1 means not stressed at all and 5 means extremely stressed, please circle the number that best describes your current level of stress.
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1 2 3 4 5
Q28. What is your main source of stress?
_______________________________________________________________
Q29. How do you usually relieve stress?
_______________________________________________________________
Q30. When you are worried, upset or under stress, how many people can you really count on to understand how you are feeling?
1. No one
2. 1 or more people
10. MC record:
Q31. How many days sickness did you take in the last 12 months?
_______________________________________________________________
11. Work Environment:
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Q31. The statements below refer to your perception of your work environment. To what extent do you agree or disagree with each statement?
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Based on the above scale of 1 to 5, where 1 means “do not agree at all” and 5 means “strongly agree”, please write the number that best describes your views. |
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a. I am proud to say I work at _____________________________ (Name of Organisation/Company) |
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b. I see the connection between the work I do and the organisation’s overall strategic objectives. |
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c. My workload is a cause of concern to me. |
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d. My work gives me a sense of accomplishment. |
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e. My contributions at work are recognised. |
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f. At work, my opinions and ideas seem to count. |
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g. I am given adequate authority to make decisions appropriate to my job scope. |
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h. I can easily balance the demands of work and home life. |
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| Results of this questionaire will be included in the final periodic medical report that will be sent to you upon completion. |