Personal Wellness Profile Questionnaire - Part III
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Date:
	1	Enter your name and surname then select the correct response for each question
Name:
Surname:
Yes No		I do not know my cholesterol level	216
44. Do you have a personal doctor?
45. Medications: Select those medications you are currently taking or take frequently.			220
	Antibiotics Blood pressure medicine Insulin or tablets for diabetes Medicine for heart disease Other medications		221
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46. Sunburn: How often do you get a heavy sunburn?
	Never about once per year 2-3 times per year More than four times per year
47. Regular exams: Select those health examinations you have had in the last 1-3 years			227
	Rectal or bowel examination Complete medical check-up Dental check upation		228
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55. Control over health and life: Select the statement that best describes your sense of control over your health, life and future happiness.
	I feel in control; what happens is largley a result of my actions I feel in control most of the time I often feel that my life is controlled or determined by outside influences and circumstances I feel trapped and have little or no control; I feel unable to change things
			238
56. Self View: I feel worthless, unimportant or inadequate...
	Most of the time Quite a lot of the time Occasionally Seldom or never
57. Women's Health: Select those items that apply to you:			239
I am currently pregnant I hope to become pregnant soon I have given birth to a child before age 30 I have reached or passed menopause I am currently taking oestrogen I am currently taking oral contraceptives I practice monthly breast self-examination I have had a mammogram in the last two years I have had a Pap smear within the last 2 years I go on a diet frequently - at least once or twice a year I sometimes take laxatives; diuretics or vomit to lose weight			240
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58. Occupational Health: How satisfied are you with your work life (skip if this does not apply to you)?
	Very satisfied Mostly satisfied Not very satisfied Very disatisfied skip
			253
59. Occupational Health: Do you feel your employer is concerned about your health and well-being (skip if this does not apply to you)?
	Yes, very much so Yes, I think so I am not sure No. My employer is not very health conscious skip
			254
60. Occupational Safety: Do you think your employer is concerned about your safety and takes precautions
	against work site health hazards  (skip if this does not apply to you)?
	Yes, very much so Yes, I think so I am not sure No. My employer is not very safety conscious skip
			255
61. Educational Level (optional): Select the highest level completed:
	Primary school O levels Trade school/technical institute A levels University Post-graduate degree skip
			256
62. Job Description: Select the one that best describes the kind of work that you do:
	Office worker Sales/marketing Managerial/administrative Professional Technician Homemaker Hospitality services Craft/trade Agriculture/labourer Equipment operator Factory worker Student Retired Other
			250
A. Health status: In general, would you say that your health is:
	Excellent Very good Good Fair Poor
			251
B. Health change: Compared to one year ago, how would you rate your present health?
	Much better Somewhat better About the same Somewhat worse Much worse
48-54. Personal Health Changes: Indicate how confident you are about improving each personal health habit as follows:
	1 = I am very confident        2 = I am moderately confident      3 = I am slightly confident
			230
	4 = I am unlikely to achieve this goal     5 = not applicable
			231
	1 2 3 4 5	I will stop smoking or remain a non-smoker
			232
	1 2 3 4 5	I will exercise for 30 or more minutes three or more times per week
			233
	1 2 3 4 5	I will eat healthy meals most of the time - foods low in fat and cholesterol, high in fibre, moderate in sugar and salt
			234
	1 2 3 4 5	I will avoid alcohol or drink moderately - no more than two drinks on per day
			235
	1 2 3 4 5	I will lose weight if I am overweight, or I will maintain a healthy weight by eating well and keeping active
			236
	1 2 3 4 5	I will manage stress with adequate time for rest, relaxation and recreation
	1 2 3 4 5	Overall, I will live a healthy lifestyle most of the time
			265
63. Workplace health problems or hazards: Score the following potential health problem or hazard at your work site as follows:
			266
	(Go to the next question if this is not applicable)
			267
	1 = bothers me a lot     2 = bothers me to some extent      3 = little or no problem to me
			268
	1 2 3	Excessive heat or cold
			269
	1 2 3	Inadequate ventilation
			270
	1 2 3	Frequently exposed to second-hand cigarette smoke
			271
	1 2 3	Too much noise
			272
	1 2 3	Poor or insufficient work space
			273
	1 2 3	Excessive litter or messy work space
			274
	1 2 3	Poor lighting
			275
	1 2 3	Inadequate protection from unsafe working conditions
			276
	1 2 3	Have to work with people under the influence of alcohol or drugs
			277
	1 2 3	Not enough safety training
	1 2 3	Too much heavy lifting	291
	1 2 3	Eye strain
	1 2 3	Exposed to dangerous chemicals or biological agents
	1 2 3	Unsafe machinery or equipment
			314
	1 2 3	Inadequate protection from electrical or radiation hazards	315
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	1 2 3	Inadequate protection from fire or explosion hazards	317
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	1 2 3	Poorly designed workstation, or long periods sitting or standing	319
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64. Exercise level: What level of activity would you prefer in your exercise programme?			321
	Easy level: I am in fairly good health and wish to start or continue an easy programme Moderate level: I am in good health and used to regular exercise, but not ready for or interested in vigorous activity Vigorous level: I am in excellent health, getting regular exercise, and want to participate in vigorous activities and maintain a high fitness level Not able: I am not able to exercise due to a current health problem or disability		322
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66. Health Interests Survey: Select those activities you would PAY to participate in if they were made available.			327
	Stop smoking programme Weight control