questionnaire Basic Information Full Name Email Age Gender Male Female Corporate Code Department Select the department Commercial Communications Design Facilities Finance Franchise Global Procurement GM Health & Safety HR Insights IT Legal Marketing R&D Sales Security Strategy Supply Chain Transformation Location Select the location HQ Plant Sales Phone Send OTP Section 1: How stressed are you ? Instructions The following questions ask about your feelings and thoughts during THE PAST MONTH. In each question, you will be asked HOW OFTEN you felt or thought a certain way. The best approach is to answer fairly quickly and tell me the answer that in general seems the best. 1. In the past month, how often have you been upset because of something that happened unexpectedly? Never Almost never Sometimes Fairly Often Very Often 2. In the past month, how often have you felt unable to control the important things in your life? Never Almost never Sometimes Fairly Often Very Often 3. In the past month, how often have you felt nervous or stressed? Never Almost never Sometimes Fairly Often Very Often 4. In the past month, how often have you felt confident about your ability to handle personal problems? Never Almost never Sometimes Fairly Often Very Often 5. In the past month, how often have you felt that things were going your way? Never Almost never Sometimes Fairly Often Very Often 6. In the past month, how often have you found that you could not cope with all the things you had to do? Never Almost never Sometimes Fairly Often Very Often 7. In the past month, how often have you been able to control irritations in your life Never Almost never Sometimes Fairly Often Very Often 8. In the past month, how often have you felt that you were on top of things? Never Almost never Sometimes Fairly Often Very Often 9. In the past month, how often have you been angry because of things that happened that were outside of your control? Never Almost never Sometimes Fairly Often Very Often 10. In the past month, how often have you felt that difficulties were piling up so high that you could not overcome them? Never Almost never Sometimes Fairly Often Very Often Section 2: How fit are you ? Do you prefer walking or running test Walking Running Time (In Minutes) to walk 2 kms (max 30 minutes) Section 3: How healthy are you ? Fasting Blood Sugar < 100 100-125 > 125 I don't know Resting Heart Rate (beats per minute) 40-60 60-90 90-100 > 100 I don't know Oxygen Saturation (SPo2) 95-100 % 90-95 % < 90 % I don't know BMI < 18.5 - Underweight 18.5 - 24.9 - Healthy Weight 25.0 - 29.9 - Overweight > 30.0 - Obese Do you visit your dentist every six months for regular check ups. Always Sometimes Never Do you visit your physician annually for routine check-ups, health screenings, and disease prevention ? Always Sometimes Never Do you get a mammogram test done anually to check for breast cancer? Always Sometimes Never Do you get a pap smear test done annually to check for cancer of the cervix? Always Sometimes Never Do you see your doctor annually for Prostate examination. Always Sometimes Never Do you get your bone densitometry test anually to diagnose osteoporosis? Always Sometimes Never Section 4: Lets assess your Lifestyle Do you smoke ? Yes No Whats your alcohol consumption I dont consume alcohol Social drinker 1-2 drinks per week/month Regular Drinker 3-6 drinks per week Habitual drinker > 6 drinks per week Whats your activity level I am a couch potato I workout/walk/run 1-2 times a week I workout/walk/run 3-4 times a week I am a fitness freak and usually dont miss out on exercise Whats your nutrition habits ? I am very inconsistent with my diet or timings I eat usually clean except 2-3 days per week I am very particular about clean eating and timings Do you eat at least two servings of fruits and vegetables every day (one serving equals one half cup). Always Sometimes Never Do you eat home cook food Always Sometimes Never On a typical day, do you take at least one servings of protein rich foods (example: dal, milk, paneer, curd, egg, chicken or mutton) Always Sometimes Never Section 5: General Health Risk Instructions Below you will find a list of statements. Please rate how true each statement is for you. Use the scale to make your choice. 1. How frequently do you suffer from back pain? Never or Almost Never Occassionally Often Always or Almost Always 2. Have you consulted a doctor/physiotherapist for back pain ? Yes No 3. How frequently do you have headaches Never or Almost Never Occassionally Often Always or Almost Always 4. How frequently do you have acidity or gastric related problems Never or Almost Never Occassionally Often Always or Almost Always 5. How frequently do you have allergy problems Never or Almost Never Occassionally Often Always or Almost Always 6. I would rate my overall physical health as Good compared to others of my age Yes No 7. Do you have Diabetes Yes No 8. Are you currently taking regular treatment (Ayu/Allo/Homeo/Herbal) for your diabetes? Yes No 9. Do your immediate family member have Diabetes (Parents/Sister/Brother) Yes No 10. Do you get HBA1c test done quarterly / yearly to monitor diabetes Never or Almost Never Occassionally Often Always or Almost Always 11. Do you have history of one or more chronic diseases like high blood pressure,stroke, heart attack. Yes No 12. Do your immediate family member have history of one or more chronic diseases like high blood pressure,stroke, heart attack. Yes No 13. How often do you feel breathlessness Never or Almost Never Occassionally Often Always or Almost Always 14. How often do you feel pain in your chest Never or Almost Never Occassionally Often Always or Almost Always 15. Do you currently have or had previous history of cancer ? Yes No 16. Do you have family history of cancer ? Yes No 17. Have you developed cyst or lump at part of your body Never or Almost Never Occassionally Often Always or Almost Always 18. Do you have White patches inside your mouth or white spots on your tongue? Yes No 19. Have you experienced unusual bleeding or discharge Yes No 20. How frequently do you get asthamatic attacks? Never or Almost Never Occassionally Often Always or Almost Always
