HeartAware

How old are you?

Section 1

Section 1 - Exercise

Moderate exercise is brisk walking, jogging, cycling, swimming, playing sports or any exercise that increases breathing and heart rate continuously for at least 20 minutes.

Section 2 - Smoking

Section 3 - Passive smoking (a non-smoker exposed to smoke most days at home or work)

Section 4 - Alcohol

Section 5 - Binge Drinking

Do you consume:

Section 6 - Environment

Secion 1 - Have you experienced any of the following events in the past 6 months?

Secion 2 - Do you participate in any of the following activities for more than an hour a week?

Do you feel anxiety, worry, fear, sudden feelings of panic, inability to control breathing and accelerated heart rate

Do you have feelings of sadness, depression, hopelessness, apathy, gloom, helplessness, isolation, loneliness, or lack of interest in social interaction?

Are you easily angered or frustrated, feel resentment or hostility towards others or frequently irritable?

Section 1 - How many hours of sleep do you have on average per night?

Secion 2 - Do you experience any of the following?

Check if applicable

Section 1 - Do you regularly experience lower abdominal pain, gas, bloating, diarrhoea, constipation, straining when passing bowel motions, excessively smelly stools and/or a feeling that your bowels do not completely empty?

Section 2 - Have you taken the oral contraceptive pill for more than 6 months in the last year?

Section 3 - For what length of time have you been on antibiotics in the last year?

Section 1 - Do you feel your energy levels drop within an hour of eating? and/or Do you experience cravings for sweets or chocolate? and/or Do you have headaches or an inability to concentrate which is relieved by eating?

Section 2 - Are you diabetic?

Section 1 - Do you experience any of the following symptoms more than once a month?

Section 2 - Do you experience recurrent pain?

How often do you usually eat fried foods?

How many serves of bread, pasta, rice, potatoes or other starchy foods do you have a day?

One serving: handful of dried pasta, slice of bread, 2-3 small potatoes.

How many servings of sweet foods like cakes, biscuits, lollies and/or chocolate do you consume a day?

How many teaspoons of sugar do you consume daily in hot drinks, added to foods, etc.?

How often do you usually eat fish?

How many pieces of fruit do you usually eat a day?

Banana, apple, orange, handful of strawberries, etc.

How many serves of vegetables (excluding potatoes) do you usually eat a day?

One serving: approximately 1 handful.

How many cups of coffee do you usually drink a day?

How much sugary soft drinks do you consume on average?

How much water do you drink a day?