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Lifestrong Health Questionnaire

Relationship status
Employment status
Are you retired?
Do yo have a disability?
Do yo have any allergies?
1. In general, how would you rate your overall health?
2. During the past seven days, how would you rate your sleep quality overall? Consider how many hours of sleep you got, how easily you fell asleep, how often you woke during the night (except to go to the bathroom), how often you woke up earlier than you had to in the morning, and how refreshing your sleep was. Please mark only one box. 0 = terrible, 5 = fair, 10 = Excellent
5. How do you feel about your weight?
6. Have you tried to lose or gain weight in the past?
7. How many serves (see below) of fruit do you usually eat each day?
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Each of the above represents a single serve of fruits and provides about 350 kilojoules.

8. How many serves (see below) of vegetables do you usually eat each day?
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Each of the above represents a single serve of vegetables and provides 100-350 kilojoules.

9. In an average week, how many serves (see below) of discretionary foods do you usually eat each day?
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Each of the above represents a single serve of discretionary foods and provides 500-600 kilojoules.

10. In an average week, how many serves (see below) of soft drinks, cordials, sports drinks, caffeinated energy drinks or other sugar-sweetened beverages do you usually drink each day?
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Each of the above represent s a single serve of sugar sweetened beverages and provides 500-600 kilojoules.

11. Over the past two weeks, have you felt down, depressed, or hopeless?
12. Over the past two weeks, have you felt little interest or pleasure in doing things?
13. If you answered yes to one of the above, is this something with which you would like help?
14. Do you smoke cigarettes?
15. Have you ever smoked? If no, go to question 18.
16. On the days you smoke, how soon after you wake up, do you have your first cigarette?
17. How many cigarettes do you typically smoke per day?
18. How often do you have a drink containing alcohol?
19. How many drinks containing alcohol do you have in a typical day when you are drinking?
20. How often do you have 4 or more standard drinks (see below) on one occasion?
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The following are examples of the number of standard drinks in some typical alcoholic beverages. A standard drink is any drink containing 1 0g of alcohol.

21. How often do you use recreational drugs (cannabis, ecstasy, cocaine, meth) or misuse prescription drugs?
24. For each of the three lifestyle areas you wish to make changes, how important are these changes to you right now? Place the numbers 1-3 in the relevant boxes. 0 = Not at all, 5 = somewhat, 10 = Very
25. How confident are you about making these changes? Place the numbers 1-3 in the relevant boxes. 0 = Not at all, 5 = somewhat, 10 = Very

Thanks for submitting!

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