Yes No Personal Wellness Profile Questionnaire - Part I
		Have you submitted a questionnaire before?
Date:
		Enter your name, surname, address, phone, e-mail, etc.; select your title, age, sex, height, etc.; then select the correct response for each question
Name:
Surname:	Mr. Mrs. Ms. Miss Dr. Rev. Sr.
Address:
City:
Country:	Antigua & Barbuda Aruba Bahamas Barbados Belize Cayman Islands Cuba Dominica Dominican Republic Grenada Guadeloupe Haiti Jamaica Martinique Puerto Rico St. Kitts & Nevis St. Lucia St. Vincent and the Grenadines Trinidad & Tobago Turks & Caicos  Islands Virgin Islands Other:
Phone:
E-Mail:
Employer:
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 male female non-metric metric Age:		yrs
Sex:
Units:
Weight:
1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.87 1.88 1.89 1.90 1.91 1.92 1.93 1.94 1.95 1.96 1.97 1.98 1.99 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 4 5 6 0 1 2 3 4 5 6 7 8 9 10 11 Height:
Frame size:grasp your right wrist tightly with your left thumb and index finger, overlapping them as much as possible.
* if your thumb and index finger do not touch then your frame size is large
* if your thumb and index finger overlap by more than 1/2 inch then it is small
* otherwise your frame size is medium
	small medium large
01. Ethnicity:   (Optional)
Caucasian (white) African East Indian Hispanic Oriental Mixed/Other skip
02. Marital Status:   (Optional)
Single Widowed Married Separated/divorced Live-in partner skip
03. Family Income level per year:   (Optional)
Less than $60000 $60000-$89999 $90000-$119999 $120000-$179999 $180000-$299999 $300000 or more skip
04. Family Health History: Have any of your immediate family members (parent, brother, sister) ever had any of the following health problems?
	Bowel cancer Breast cancer before age 52 Diabetes Heart attack; coronary artery disease; or died suddenly before age 55 of unknown cause High blood pressure	Bowel cancer
		High blood pressure or stroke
		Breast cancer before age 52
		Diabetes
		Heart attack, coronary artery disease, or died suddenly before age 55 of unknown cause
05. Personal Health History: Has a physician Informed you that you currently have any of these health problems?
	Cancer Diabetes/ high blood sugar Coronary heart disease/Heart attack; by-pass surgery Bowel polyps or inflammatory bowel disease Chronic bronchitis or emphysema Stroke or poor circulation to head or legs Asthma High blood pressure (hypertension) Backache (slipped/ruptured/bulging discs) Rheumatoid arthritis Osteoarthritis Constipation Psoriasis
	Other:
06. Current Symptoms: Indicate any of these symptoms you have experienced recently.
	Heavy chest pain/discomfort; frequent palpitations; fluttering of the heart Unusual shortness of breath Unexplained dizziness or fainting Significant unexplained weight loss Ankle oedema (swelling of ankles from retained fluids) Frequent joint pains or arthritis Frequent urination with unusual thirst Frequent coughing; wheezing or difficulty breathing Thickness or lump in breast Frequent back pain
07. Aerobic exercise: How many times per week do you engage in aerobic exercise of at least 20-30 minutes duration
	(activities such as cycling, swimming, aerobic dance, jogging, active sports, brisk walking, and sustained vigorous work)?
Do not have a regular exercise programme Once per week Twice per week Three or Four times per week Five or more times per week
08. Strength exercises: How often do you do strength building exercises such as sit ups, push ups, or use weight training equipment?
	Seldom or never Once or twice per week Three or more times per week
09. Stretching exercises: How often do you do stretching exercises for the back, neck, shoulder or calves?
	Seldom or never Once or twice per week Three or more times per week
10. Exercise level: Indicate your average level of physical activity over the last month
	Avoid walking or exertion whenever possible, always use the elevator, drive whenever possible instead of walking Occasionally walk for pleasure or execise enough to breathe heavily or sweat Light exercise programme - less than one hour per week Light exercise - one to two hours per week Moderately heavy exercise - but less than one hour per week Run 1-5 miles or walk 2-6 miles, or 1-2 hours of other vigorous exercise per week Run 6-10 miles or walk 7-13 miles, or 3-4 hours of other vigorous exercise per week Run 11-15 miles or walk 14-20 miles, or 5-6 hours of other vigorous exercise per week Run 16-20 miles or walk 21-25 miles, or 7-8 hours of other vigorous exercise per week Run 21-25 miles or walk 26-30 miles, or 9-10 hours of other vigorous exercise per week Run more than 35 miles or walk 30 miles, or more than 10 hours of other vigorous exercise per week
Weight is about right; no desire to change Overweight; would like to trim down Overweight, but not interested in changing Underweight 11. Weight: How do you feel about your present weight?
Click on Submit and then proceed to Part II of the questionnaire