Lifestyle Questionnaire - Innovate Occupational Health

Patient details:

First Name*

Surname*

Email*

Phone Number*

Date of Birth*

Company*

Company Site*

GP contact details:

Current GP Name*

Practice Name*

Address line 1*

Postcode*

Contact Number*

Consent:

The questionnaire will take approximately 10 minutes to complete. The questions will assess your General Health and Wellbeing. After which, you will receive an outcome report and your responses will be stored by Innovate Healthcare.

Only approved representatives from Innovate Healthcare will have access to the individual question responses.

Information regarding the online questionnaire:

This questionnaire will consist of Physical and Mental health questions. Please answer all questions as accurate as possible.

Following completion of the questionnaire, a copy of your outcome report will be emailed to you which a technician will review during your face-to-face assessment.

The outcome report will have colour gradings for categories, for example, Exercise will be graded as green if you meet the recommended guidelines set out by the NHS, if you are below the recommendations this will be graded as Amber or Red.

Information sources will be provided for guidance.

Exercise

How much exercise do you get per week?*

0-49 minutes

50-99 minutes

100-149 minutes

150+ minutes

How many days of resistance training do you do per week?*

0

1

2

3+

Alcohol

Do you drink alcohol?

On those days you drink, how much would you typically consume?*

Pint of beer or cider (568ml)

Glass of wine (175mm)

Single shot spirits (25mm)

Bottle of beer or cider (330ml)

Choose Value*

0-4 units

5-9 units

10-14 units

14+ units

Smoking

Do you smoke?*

Daily

Socially

Never smoked

No, I quit

Cigarettes/Roll-ups/Vape?*

How many per day?*

How long have you smoked for?*

When did you stop smoking?*

PHQ-9 questionnaire

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things*

Feeling down, depressed or hopeless*

Trouble falling asleep, staying asleep, or sleeping too much*

Feeling tired or having little energy*

Poor appetite or overeating*

Feeling bad about yourself - or that you're a failure or have let yourself or your family down*

Trouble concentrating on things, such as reading the newspaper or watching television*

Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual*

GAD-7 questionnaire

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious or on edge*

Not being able to stop or control worrying*

Worrying too much about different things*

Trouble relaxing*

Being so restless that it is hard to sit still*

Becoming easily annoyed or irritable*

Feeling afraid as if something awful might happen*