HEALTH STATUS OF CBM

Individual : Age : Gender : Weight : Regular Student (21-23) Female (50-60 Kgs) (60-70 Kgs) (Above 70 Kgs) Executive Student (24-28) (28-40) Faculty Member (Above 40) (18-20) Male (40-50 Kgs)

Questions..............................................................................................
1. In general, would you say your health is ________________________. (Circle one) a) Excellent b)Very Good c)Good d)Fair e)Poor 2. What is the average number of hours you spend sleeping everyday? a) 4-6 hrs b) 6-8hrs c) 8-10 hrs d)10-12 hrs e) More than 12 hrs 3. Do you have breakfast everyday in the morning? a) Always b) Sometimes c) Never 4. Are you exposed to constant pressure and stress? a) Always b) Sometimes c) Never 5. Do you excercise regulary or do any sports? a) Always b) Sometimes c) Never 6. Are you conscious about maintaining a healthy diet? a) Always b) Sometimes c) Never 7. Do you face any of the followin issues? a) Migarine b)Nausea c) Asthema d) Skin disease e)None of these 8. Do you smoke? a) Yes b)Sometimes c)Not at all 9. Do you feel exhausted while climbing the stairs? a) Yes b)Sometimes c)Never

10. How often do you see a doctor? a) Once a month b)Twice a month c) Once in two months d) Hardly ever 11. Do you take any of the following medicines very frequently? a) Panadol b) Xanax c) Ponstan d) Tylenol 12. Have you ever been tested for Hepatitis? a) Yes b) No 13. Have you ever had an anxiety attack? a) Yes b) No 14. Have you ever been treated for emotional problems? a) Yes b) No 15. Are you prone to excessive depression? a) Yes b) No 16. How often do you have CBM Cafeteria food? a) Everyday b) Once in 2 days c) Once in a week d) Never 17. What do you prefer the most for you routine meals? a) Vegtables b)Meat c) Chicken d)Junk Food

Participant Signature: ______________________