Nicole Brown Survey For Health & Social


     

     

Name: 


A red asterisk (*) indicates required questions.

  1. What gender are you? *
    Male
    Female


  1. What age are you? *
    16-20
    20-24
    24-30
    30-50
    50+


  1. What religion are you?
    Christian
    Protestant
    Muslim
    Other


  1. Do you think that your area in which you live has any effect on you leading a healthy lifestyle*
    Yes
    No


  1. On a rate from 1 – 9, 1 being the lowest and 9 being the highest, how would you rate your health? *
    1 2 3 4 5 6 7 8 9


  1. Do you smoke? *
    Yes
    No


  1. How many cigarettes would you smoke per day?*
    0-10
    10-20
    20+


  1. At what age did you start smoking? *
    16-20
    20-25
    25-30
    30+


  1. Why did you start? *


  1. Could you name three health problems caused by smoking? *


  1. Has known the effects of smoking ever encouraged you to quit?*
    Yes
    No


  1. Do you drink alcohol? *
    Yes
    No


  1. What alcohol would you mainly drink?
    Spirits
    Wine
    Beer
    Other


  1. What do you think ‘binge drinking’ is?*


  1. Name three illnesses that you think alcohol causes*


  1. When you drink do you go over your limits?*
    Yes
    No


  1. Have you ever been in any serious trouble due to alcohol?*
    Yes
    No


  1. Do you exercise regularly?*
    Yes
    No


  1. If yes, what exercise are you most likely to do?


  1. If no, please state why you don’t


  1. Do you think that it is important to get regular exercise? *
    Yes
    No


  1. 22. ‘Regular exercise is a critical part of staying healthy. People who are active live longer and feel better. Exercise can help you maintain a healthy weight. It can delay or prevent diabetes, some cancers and heart problems.’*
    Strongly Agree
    Agree
    Unsure
    Disagree
    Strongly Disagree


  1. Why do you think people gain more weight when they get older?*


  1. How often do you weigh yourself?*
    Everyday
    Every week
    Every month
    Every year
    Never


  1. Have you felt been paranoid about your weight? *
    Yes
    No


  1. If yes, has this ever encouraged you to gain/loose weight? *
    Yes
    No


  1. Describe what a healthy diet is*


  1. Do you think you lead a healthy diet
    Yes
    No


  1. Do you have your ‘5 a day’?
    Yes
    No


  1. How often do you visit your GP? *
    Every couple of weeks
    Every couple of months
    Yearly
    Never


  1. Why would you visit your GP?*


  1. Do you think you should visit your GP more often? *
    Yes
    No





Mrs Ennis