Please Select Your
Age
16-25
26-30
31-40
41-50
51-60
61-70
70+
Please Select Sex
Male
Female
Others
Smoking
Do You Smoke?
Please Select
Yes
No
Drinking
How often do you have a drink containing alcohol?
Please Select
Yes
No
Exercise
Do you do any exercise/physical activity?
Please Select
Yes
No
Eating
Do you eat fruit and/or vegetables?
Please Select
Yes
No
Mental Health
Do you feel you have someone to talk to if you have a problem or are
in a situation that is worrying or concerning you e.g family,friend, Doctor,
colleague?
Please Select
Yes
No
Physical Health
Have you taken part in a national or local campaign in the last year
to improve your health (for example: joined one of the on-site fitness classes, enrolled
at a gym, walk to work month, Dry January or Stoptober)?
Please Select
Yes
No
Have you increased your levels of walking in the last year?
Please Select
Yes
No
How do you travel to work?
Please Select
Walk
Cycle
Drive
Public Transport
Shuttle Bus
Other
Mindfulness
Are you aware of opportunities to take part in mindfulness
initiatives (For example: mindfulness study days, stress management course, breathing
exercise...)?
Please Select
Yes
No
Have you taken part in any mindfulness opportunities?
Please Select
Yes
No
Do you have a long term, stable medical condition that requires
regular medicine in the short to medium term?
Please Select
Yes
No
Submit
