Alcohol and Exercise Questionnaire

Please complete the questionnaire for your Health Check Appointment. If you do not want to attend for a check then we would appreciate having the completed form anyway.

Alcohol and Exercise Questionnaire

Alcohol and Exercise Questionnaire

If you are human, leave this field blank.

Patient Details

First Name(s): *

Surname: *

Date of Birth: *

Please use date format: DD/MM/YYYY

Phone Number:

Email Address: *

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Physical Activity

Please tell us the type and amount of physical activity involved in your daily life: *

I am not in employment (e.g. retired, retired for health reasons, unemployed, full-time carer etc.)

I spend most of my time at work sitting (such as in an office)

I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.

My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.

My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc. *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Cycling, including cycling to work and during leisure time *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Walking, including walking to work, shopping, for pleasure etc. *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Housework / Childcare *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Gardening / DIY *

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

How would you describe your usual walking pace? *

Slow pace (ie. less than 3mph)

Steady average pace

Brisk pace

Fast pace (ie. over 4mph)

Smoking

Smoking status: *

Smoker

Ex Smoker

Never Smoked

When did you quit? *

How many per day did you used to smoke? *

How many/much do you smoke? *

Please select one: *

Cigarettes per day

Oz/Grams of tobacco per week

Would you be interested in stopping smoking and/or attending a stop-smoke clinic? *

Yes

No

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