Health Status Survey
Instructions: Please complete the questions below and be as detailed as possible. If at any time you do not understand a question or have any type of query please do not hesitate to ask.
Name: David Smith
Height: 179 cm
Occupation: Construction worker
1. How often do you exercise? Never
2. What type of activities do you do? Lifting on the construction site
3. Please indicate the average level of intensity of the exercise you would normally take part in.
b) Moderate- Vigorous
d) Passive- Passive
4. What does your average daily diet consist of? Breakfast: Can of V Morning tea: Pie and sauce, coke Lunch: Kebab (meat, tomato, lettuce, cheese), coke Afternoon tea: Vanilla slice and coke Dinner: steak, potato and peas, coke
5. Do you eat the recommended 3 serves of fruit and five serves of vegetable a day? No fruit, lettuce, tomato, peas and potato
6. How much water do you drink a day? 2 glasses
7. How many mL of soft drink do you drink a day? 1500mL
8. Do you have any medical conditions? Bad back, depression
9. Do you take any prescription medications, if so what do they treat? Yes, depression
10. Is there a history of hereditary diseases in your family, if so what are they? Diabetes, heart disease
11. Do you smoke, if so how many a day? Yes, 15 cigarettes
12. How many times a week would you consume alcohol? Every day approx. 3 beers
13. Have you ever taken illicit drugs, if so how regularily? Smoke marijuana maybe twice a year
14. How many hours of sleep do you get a night on average? 6 hours
15. What type of sun protection do you use? Sunglasses
16. How often do you use sun protection? Sunglasses daily, no sunscreen, no hat.
1. Do you find it easy to socialise with people you know well and strangers? yes
2. Are you currently in a...