Behavioral Factors

Behavioral Factors

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1. Daily Activity Factor (Physical Activity)

(i). How many days a week do you usually exercise? *

0
1
2
3
4
5
6
7

(ii). On days when you exercise, for how long do you usually exercise? *

0-20 minutes per day
20-30 minutes per day
30-45 minutes per day
45 or more minutes per day
Does not apply

(iii). How intense is your typical exercise? *

Light (like stretching or slow walking)
Moderate (like brisk walking)
Heavy (like jogging or swimming)
Very heavy (fast running or stair climbing)
I am currently not exercising

2. Fitness Assessment

(i). Body composition

BMI
WHR (Waist Hip Ratio)
% Body Fat

%

(ii). Cardiovascular Endurance

VO2 max

ml/kg/min
20m Multistage Fitness Test (Beep Test)

ml/kg/min

(iii). Strength & Strength Endurance

Muscle Strength (isometric strength Hand & forearm)

pounds
Grip Strength (Males and Females)

pounds
4 level Abdominal Strength
- Cannot perform
- Difficulty performing, jerky motion, feet leave the floor
- Uses a lot of momentum to overcome 45 degrees
- Performs with slight pause in the mid area of the sit-up
- No difficulty

(iv). Muscular Strength Endurance

Upper body (Push-Ups test)

times
Core (1 Minute Situp Test)

times
Lower Body (Squat test)

times

(v). Flexibility

Sit & Reach Flexibility Test

cm

3. Smoking/Tobacco Use

(i). Do you currently smoke cigarettes or use other types of tobacco?*

Yes
No

(ii). Are you a former smoker?*

Yes
No
Does not apply

(iii). If you quit smoking, how long ago did you quit smoking cigarettes? *

Less than 6 months ago
6-11 months ago
1-5 years ago
6-10 years ago
More than 10 years ago
Does not apply

(iv). Do you use these other tobacco products?*

Cigars
Pipes
Chewing tobacco/snuff
I use no other tobacco products

4. Second Hand Smoke

Are you often exposed to people smoking near you at home or at work? *

Yes
No

5. Alcohol Use

(i). Are you currently pregnant?*

Yes
No
Does not apply

(ii). In a typical week, how many days do you drink alcohol? *

0
1
2
3
4
5
6
7

(iii). On days when you drink alcohol, how many alcoholic drinks do you consume? *

None
1-3
4-7
8 or more

(iv). In a typical week, how often do you have 5 or more alcoholic drinks on one occasion? *

Never
Once a week
2-3 times per week
More than 3 times per week

6. Drugs

How often do you use prescription drugs or other drugs that help you relax or can affect your mood?*

Rarely or Never
Occasionally
Almost every day

7. Nutrition

(i). Fruits

On a typical day, how many servings of fruits do you eat? (1 medium piece of fruit such as orange or banana, 1 cup of fresh fruits, ½ cup cooked fruits, 1 cup = size of a baseball)*

(Last picked from Health Actions - Intuitive Plate as on Sep 17, 2016)

0-½
1
1 and 1/2
2
2 and 1/2
3
3 and 1/2
4 or more

(ii). Vegetables

On a typical day, how many servings of vegetables do you eat? (1 serving = 1 cup of fresh vegetables, ½ cup of cooked vegetables, 2 cups of greens, 8 oz. (1 cup) vegetable juice1 cup = size of a baseball)*

0
½-1
1 and ½ - 2
2 and ½
3
3 and 1/2
4 or more

(iii). Proteins

On a typical day, how many servings of proteins do you eat? (1/2 cup of tofu, peas or beans, 1 vegetarian burger, 2 eggs, 2 oz. (1 cup) lean meat, poultry or fish, 1 deck of card size hamburger)*

0
1
2
2 and ½
3
3 and 1/2
4 or more

(iv). Whole Grains

On a typical day, how many servings of high fiber or whole grain foods do you eat? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole wheat pasta)*

0
1
2
3
4
5
6 or more

(v). Fats

On a typical day, how many servings of fried or high-fat foods do you eat? (Examples include fried chicken, fried fish, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese, or mayonnaise)*

0-1
2
3
4
5 or more

(vi). Treats/Sweets

On a typical day, how many servings of 'treats/sweets' do you eat? (Examples include for desserts: 1 candy, 1 cookie, ½ cup ice cream, 1 small piece of cake or pie; or 8 oz. soft drinks, 2 Tbsp jelly or syrup)*

0-1
2
3
4
5 or more

(vii). Water

On a typical day, how many cups (8 oz.) of water do you drink?*

0
1
2
3
4
5
6
7
8 or more

(viii). Milk

On a typical day, how many cups (8 oz.) of low-fat milk or non-fat milk do you drink?*

0
1/2
1
1 and 1/2
2
2 and 1/2
3 or more

8. Motor Vehicle Safety

(i). Do you always fasten your seat belt when you are in the car?*

Yes
No

(ii). Do you ever drive after drinking, or ride with a driver who has been drinking?*

Yes
No

9. Helmets

Do you always wear a helmet when on a bicycle, motorcycle, skiing etc.?*

Yes
Sometimes
No

10. Sun Exposure

Do you protect yourself from the sun when you are outdoors?*

Yes Always
Most Often
Not Often
Not At All

11. Social Determinants of Health

(i). Marital Status*

Married
Unmarried

(ii). Do you currently Live Alone?*

Yes
No

(iii). Do you often feel lonesome?*

Yes
No

(iv). Are you currently a Single Parent?*

Yes
No
Does not apply

(v). Have you had a Serious Relationship Problems within the past 12 months?*

Yes
No

(vi). Have you had a Personal Crisis within the past 12 months?*

Yes
No

(vii). Do you currently living in an area that is considered high in crime?*

Yes
No

(viii). Do you view your current dwelling to be crowded?*

Yes
No

(ix). Are you currently caring for an Elderly Parent?*

Yes
No

(x). Have you been victim of "Domestic Violence/Abuse" within the past 12 months?*

Yes
No