0 1 2 3 4 5+
2 - How often do you
Eat out at a café or restaurant?
Never Occasionally Several times a week Once a day Several times a day
Eat a take-away?
Eat crisps or similar snacks?
Drink sugary drinks such as fizzy pop, juice or syrupy coffee?
Eat sugary snacks such as biscuits, cake, sweets or chocolate?
Eat a ready meal?
0 1 2 3 4 5 6 7 8 9 10
5 - On a scale from 0 -10, how confident are you that you can make these changes?
0 1 2 3 4 5 6 7
Yes No
I have never smoked /haven’t smoked in the last 2 years I recently quit I smoke
You have indicated that you are currently smoking. Effective support is available to make it easier to stop and which will increase your chances of quitting for good! Get FREE support from Smokefree Sefton because you are four times more likely to quit successfully with their help. Ring them on 0300 100 1000.
Daily Weekly or Less frequently
31 or more 21 to 30 11 to 20 10 or less
within 5 minutes 6 – 30 minutes More than 30 minutes
2 - What is your waist measurement?
Inches cm
4 - On a typical day, how many portions of fruit and vegetables do you eat?
0 1 2 3 4 5 More than 5
Look at the following statements and tick the buttons that best describes your thoughts and feelings over the last two weeks.
1 - I’ve been feeling optimistic about the future?
None of the time Rarely Some of the time Often All of the time
2 - I’ve been feeling useful?
3 - I’ve been feeling relaxed?
4 - I’ve been dealing with problems well?
5 - I’ve been thinking clearly?
6 - I’ve been feeling close to other people?
7 - I’ve been able to make up my own mind about things?
1 - How often do you have a drink containing alcohol?
Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4 + times per week
2 - How many units of alcohol do you drink on a typical day when you are drinking?
1 -2 3 - 4 5 - 6 7 - 9 10+
3 - How often have you had 6 or more units of alcohol, if female, or 8 or more if male, on a single occasion in the last year?
Never Less than monthly Monthly Weekly Daily or almost daily
4 - How often during the last year have you found that you were not able to stop drinking once you had started?
5 - How often during the last year have you failed to do what was normally expected from you because of your drinking?
6 - How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
7 - How often during the last year have you had a feeling of guilt or remorse after drinking?
8 - How often during the last year have you been unable to remember what happened the night before because you had been drinking?
9 - Have you or somebody else been injured as a result of your drinking?
Never Yes, but not in the last year Yes, during the last year
10 - Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No Yes, but not in the last year Yes, during the last year
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