Personal Wellness Profile Questionnaire - Part II
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Date:
		Enter your name and surname then select the correct response for each question
Name:
Surname:
1 2 3 4 5 6 7 8 9 10 11 12 Date of Birth:		1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
11. Weight: How do you feel about your present weight?
	Weight is about right; no desire to change Overweight; would like to trim down Overweight, but not interested in changing Underweight
12. Meat/Protein foods: Indicate the kind of meat/protein foods you usually eat.
	I regularly eat red meat, hamburgers, sausages and luncheon meats. I eat a mixture of regular meats and some poultry or fish I eat only lean meats, poultry, or fish I eat very little red meat, mostly white meat of poultry or fish I seldom or never eat meat/I am a vegetarian
13. Dairy products/eggs: Indicate the kinds of dairy products you usually eat.
	High fat dairy products include: ice cream, sour cream, yellow cheese, whole milk, eggs and butter.
	Low fat dairy products include: skim milk, low fat yoghurt or cottage cheese, egg whites or egg substitutes.
	I nearly always eat high fat products I eat mostly high fat products; some low I eat both about the same I eat primarily low  fat products; some high fat I eat only low  fat products or none at all
14. Desserts: Indicate the kind of desserts you usually eat:
	High fat desserts include: cake, donuts and pastry, pies, ice cream, custard, chocolate.
	Low fat desserts include: fruit salads, gelatine, melons, grapes, dried fruit, home baked goods (using vegetable oil moderately).
	I nearly always eat high fat products I eat mostly high fat products; some low I eat both about the same I eat primarily low  fat products; some high fat I eat only low  fat products or rarely eat dessert
15. Food preparation: Indicate the way your food is usually cooked, or the kind of food you usually eat.
	High fat methods: Frying, deep fat frying, primarily use shortenings, frequently add butter or other fats to foods for flavouring,
		use regular amount of fat called for in recipes and creamy dressings.
	Low fat methods: Broil, bake, or boil. Primarily use vegetable oil.
	Food nearly always cooked the high fat way Food mostly cooked the high fat way Food cooked both ways about the same Food cooked primarily the low fat way Food prepared only the low fat way
16. Breads and grains: Indicate the kind of breads you usually eat:
	Refined grain products: White bread, rolls, biscuit, crackers, regular pancakes and waffles, white rice, typical breakfast cereal, typical baked goods.
	Whole grain products: Whole grain breads; rolls; whole grain pancakes and waffles; whole grain used in baked goods;
		brown rice; oatmeal and other whole grain cereals such as shredded wheat.
	I nearly always eat refined grain products I eat mostly refined grain products I eat both about the same I eat primarily whole grain products I eat only whole grain products
17. Fruits and vegetables: How much fruit and vegetables do you eat?
	One portion equals, for example, one medium-sized banana or a cup of chopped vegetables.
	Five or more portions per day Four portions per day Three portions per day Two portions per day One portion or less per day
18. Fast foods: How often do you eat fast food meals such as hamburgers, fried chicken, hot dogs, French fries, pizza, etc.?
	Nearly every day Several times per week Few times per month Seldom or never
19. Salt: How often do you eat salty foods (chips, salt nuts, pickles, soy sauce) or add salt at the table?
	Seldom or never Occasionally Regularly Frequently; I like salty foods
20. Breakfast: How often do you eat a good breakfast (more than a sandwich and a cup of coffee)?
	I eat a good breakfast every day Almost every day Sometimes Rarely or Never
21. Snacks: How often do you eat snack foods (sweet/fatty foods and/or soft drinks - not fruits) between meals (do not forget evening snacks)?
	Three or more times per day Once or twice per day Few times per week Rarely or never
22. Drinking: On how many days, out of the last fourteen, did you drink alcohol?
	Non-drinker/did not drink in past year None in past fourteen days One to three days Four to six days Seven to ten days Eleven to fourteen days
23. Number of drinks: In past the past two weeks on the days that you drank an alcoholic beverage,
	how many drinks did you have per day on the average?
	Non-drinker/did not drink in the past year None in the past 2 weeks One Drink Two drinks Three to four drinks Five or more drinks
24. Drugs: How often do you use tablets to calm your nerves, or to help you relax or sleep?
	Frequently; every week Sometimes; monthly Rarely; few times per year Never
25. Drug interactions: When taking medications are you careful to tell your doctor about other drugs you are taking,
	and to stay away from alcohol in order to avoid harmful drug interactions?
	Yes; very careful about this No; not too careful about this I did not know about drug interactions
26. Caffeine: How many drinks of coffee, tea, Coke or Pepsi do you usually drink per day?
	None One per day Two to three per day Four to five per day six or more per day
27. Smoking status: Select the appropriate response.
	I have never smoked Quit smoking 10 years or more ago Quit smoking less than 10 years ago Smoke less than 5 cigarettes per day or smoke a pipe or cigar only Smoke less than 10 cigarettes per day Smoke 10 or more cigarettes per day
29. Stress/Coping status: Select the response that describes how you feel you are currently coping with life.
	Seldom or never stressed; coping very well Sometimes stressed; coping fairly well Often stressed; trouble coping at times Heavily stressed; often trouble coping Excessively stressed; unable to cope
30. Stress signs: Select those stress signals that you currently feel apply to you, or move on to the next question.
	Minor problems get me very upset I am finding it difficult to get along with several people Nothing seems to give me pleasure anymore I am unable to stop thinking about my problems I feel frustrated, suspicious and/or angryl much of the time I feel tense or anxious much of the time
31. Energy level: Have you felt tired, worn out, used up, or exhausted during the past month?
	Most of the time Less than half the time Only occasionally Seldom or never
32. Sleep: On the average, how often do you get at least 7-8 hours of sleep a night?
	Nearly all the time Majority of the time Less than half the time Only occasionally
33. Happiness: All in all, how happy are you these days?
	Very happy Pretty happy Not too happy Very unhappy
34. Social support system: In general, how strong are your social ties with family and friends?
	(have someone with whom to share problems/joys or get help if needed.)
	Have strong family/friend social support Have some family/friend social support Have little family/friend social support Have no close family/friend available
35. Seat belts: When driving or riding in a car, how often do you wear a seat belt?
	Always Majority of the time Less than half the time Never or only occasionally
Yes No 36. Smoke detector: Does your home have a working smoke detector near your sleeping area?
37. Lifting: When lifting heavy objects, how often do you make sure to use correct lifting techniques?
	(Keep object close to body; bend at hips and knees; keep back in normal arched position with head and shoulders up; lift with legs.)
	Always Majority of the time Less than half the time Only occasionally Seldom or never, or do not know correct lifting technique
38. Drinking and driving: During the past year, how many times did you drive when you perhaps had too much to drink?
	Do not drive; never drink; or never drive after drinking Once Twice More than twice
39. Office visits: How many visits have you made during the past 12 months to a doctors office, emergency room, psychiatrist, psychologist,
	chiropractor or other health care professional?
	None One Two Three to Five Six to nine Ten or more
40. Sick days: How many days did you miss from work (or your usual routine) due to sickness or injury during the past 12 months?
	None One to three days Four to six days Seven to nine days Ten to thirteen days Fourteen or more days
41. Hospital days: How many days did you spend in the hospital due to sickness or injury during the last 12 months?
	None One day Two days Three days Four to six days
42. Blood pressure: What is your USUAL blood pressure
	good/normal; 120/80 or below Fair/average; (121-139)/(81-89) Moderately high; (140-159)/(90-94) High; 160/95 or higher I do not know mu usual blood pressure
43. Cholesterol: Indicate your blood cholesterol level
	Good; 180 or below (less than 4.7 mmol\\l) Fair/Average; 181-199 (4.7-5 17mmol/l) Moderately high; 200-239 ( 5.2-6.2 mmol/l) High; 240 or higher (greater than 6.2 mmol/l) I do not know my cholesterol level
Click on Submit and then proceed to Part III