Demographics Information

Transcription

1 Participant # Date:_ Demographics Information Please answer the following questions about your demographics and health-related behaviours. 1. Gender: Male / Female 2. Age: 3. Height (to the best of your knowledge)? cm 4. Weight (to the best of your knowledge)? kg 5. What is your ethnic group membership? Please choose ONE of the following: NZ European/Pakeha NZ Maori Asian Other Pacific Specify: Other European Specify: Other Specify: 6. Which number represents your household s total income before taxes for the past year including salaries, wages, benefits, and other income? Less than $19,999 Between $20,000 and $39,999 Between $40,000 and $59,999 Between $60,000 and $79,999 Between $80,000 and $99,999 Between $100,000 and $119,999 Between $120,000 and $139,999 More than $140, What is the highest level of education you completed? Did Not Complete High School High School Some university study Bachelor's Degree Some postgraduate study Postgraduate Diploma Master's Degree Advanced graduate work or PhD 1

2 Participant # Date:_ 8. If you are female, please indicate where you are on your menstrual cycle. (Evidence suggests menstruation can affect female heart rate variability recordings) Currently menstruating Week 1 Mid cycle Week 3 N/A (post menopausal) No menstruation due to contraceptive Don t know/ Would rather not say 9. Are you currently sick or have an on-going illness? Yes / No If yes, please list your illness(es) 10. Are you currently taking any medications? Yes / No If yes, please list please list your medication below and the reason for taking it Medication: Reason for taking it: 11. During the past three months, how often have you drink alcohol, on average? (tick one) Not at all Less than once a week 1-2 times a month 1 2 times a week 3-6 times a week Every day 2

3 Participant # Date:_ 12. On days when you did drink alcohol in the last three months, how many drinks did you have on an average day? (tick one) 0 drinks 1 drink 2 drinks 3-4 drinks 5-6 drinks 7-11 drinks 12 or more 13. During the past three months, how often do you drink tea or coffee, on average? (tick one) Not at all Once or twice a week Once a day 1-3 times per day 3-6 times per day More than 6 times per day 14. Looking back on the past week, how often did you get less than 7 hours sleep? (tick one) Never Once Twice Three or four times Five or more times 3

4 Participant #: Date: Houston Non-Exercise Questionnaire Code for Physical Activity Circle the appropriate number (0-7) which best describes your general activity level for the previous month. DO NOT PARTICIPATE IN PROGRAMMED RECREATION, SPORT OR HEAVY PHYSICAL ACTIVITY. 0. Avoid walking or exertion, e.g. always use the elevator, drive whenever possible instead of walking 1. Walk for pleasure, routinely use stairs, occasionally exercise sufficiently to cause heavy breathing or perspiration PARTICIPATE REGULARLY IN RECREATION OR WORK REQUIRING MODEST PHYSICAL ACTIVITY, SUCH AS GOLF, HORSEBACK RIDING, PILATES GYMNASTICS, TABLE TENNIS, BOWLING, WEIGHTH LIFTING, GARDENING minutes per week. 3. Over one hour per week. PARTICIPATE REGULARLY IN HEAVY PHYSICAL EXERCISE SUCH AS RUNNING OR JOGGING, SWIMMING, CYCLING, ROWING, SKIPPING ROPE, RUNNING IN PLACE, OR ENGAGING IN VIGOROUS AEROBIC ACTIVITY TYPE EXERCISE SUCH AS TENNIS, RUGBY, OR BASKETBALL 4. Run less than 1.6 kilometres per week (less than one mile) or spend less than 30 minutes per week in comparable physical activity 5. Run 1.6 to 8.4 kilometres per week (1 to 5 miles) or spend 1 to 3 hours per week in comparable physical activity 6. Run 8.4 to 16 kilometres per week (5 to 10 miles) or spend 1 to 3 hours per week in comparable physical activity 7. Run over 16 kilometres (10 miles) per week or spend over 3 hours per week in comparable physical activity

5 Participant #: Date: Cigarette Dependence Scale (Short Form) Instructions: Please answer the following questions regarding your cigarette smoking habits. 1. Please rate your addition to cigarettes on a scale of On average, how many cigarettes do you smoke per day? cigarettes/day 3. Usually, how soon after waking up do you smoke your first cigarette? minutes 4. For you, quitting smoking would be: (please tick the response which fits you best) Impossible Very Difficult Fairly Difficult Fairly Easy Very Easy Please indicate whether you agree with each of the following statements: 1 = Totally disagree 2 = Somewhat disagree 3 = Neither Agree nor Disagree 4 = Somewhat Agree 5 = Fully Agree Totally Disagree Somewhat Disagree Neither Agree nor Disagree Somewhat Agree Fully Agree 5. After a few hours without smoking, I feel an irresistible urge to smoke The idea of not having a cigarettes causes me stress Before going out, I always make sure that I have cigarettes with me I am a prisoner of cigarettes I smoke too much Sometimes I drop everything to go out and buy cigarettes I smoke all the time I smoke despite the risks to my health

6 Participant #: Date: State Trait Anxiety Inventory Trait Form Instructions: A number of statements which people have used to describe themselves are given below. Read each statement and select the appropriate response to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement. 1 = Almost Never 2 = Sometimes 3 = Often 4 = Almost Always Almost Never Sometimes Often Almost Always 1. I feel pleasant I feel nervous and restless I feel satisfied with myself I wish I could be as happy as others seem to be I feel like a failure I feel rested I am calm, cool and collected I feel that difficulties are piling up so that I cannot overcome them I worry too much over something that really doesn t matter I am happy I have disturbing thoughts I lack self-confidence I feel secure I make decisions easily I feel inadequate I am content Some unimportant thought runs through my mind and bothers me I take disappointments so keenly that I can t put them out of my mind I am a steady person I get in a state of tension or turmoil as I think over my recent concerns and interests

7 Participant #: Date: Five Facet Mindfulness Questionnaire Instructions: Please rate each of the following statements using the scale provided. Write the number in the blank that best describes your own opinion of what is generally true for you Never or very rarely true Rarely true Sometimes true Often true Very often or always true 1. When I m walking, I deliberately notice the sensations of my body moving. 2. I m good at finding words to describe my feelings. 3. I criticize myself for having irrational or inappropriate emotions. 4. I perceive my feelings and emotions without having to react to them. 5. When I do things, my mind wanders off and I m easily distracted. 6. When I take a shower or bath, I stay alert to the sensations of water on my body. 7. I can easily put my beliefs, opinions, and expectations into words. 8. I don t pay attention to what I m doing because I m daydreaming, worrying, or otherwise distracted. 9. I watch my feelings without getting lost in them. 10. I tell myself I shouldn t be feeling the way I m feeling. 11. I notice how foods and drinks affect my thoughts, bodily sensations, and emotions. 12. It s hard for me to find the words to describe what I m thinking. 13. I am easily distracted. 14. I believe some of my thoughts are abnormal or bad and I shouldn t think that way. 15. I pay attention to sensations, such as the wind in my hair or sun on my face I have trouble thinking of the right words to express how I feel about things 17. I make judgments about whether my thoughts are good or bad. 18. I find it difficult to stay focused on what s happening in the present. 19. When I have distressing thoughts or images, I step back and am aware of the thought or image without getting taken over by it.

8 Participant #: Date: 20. I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. 21. In difficult situations, I can pause without immediately reacting. 22. When I have a sensation in my body, it s difficult for me to describe it because I can t find the right words. 23. It seems I am running on automatic without much awareness of what I m doing. 24. When I have distressing thoughts or images, I feel calm soon after. 25. I tell myself that I shouldn t be thinking the way I m thinking. 26. I notice the smells and aromas of things. 27. Even when I m feeling terribly upset, I can find a way to put it into words. 28. I rush through activities without being really attentive to them. 29. When I have distressing thoughts or images I am able just to notice them without reacting. 30. I think some of my emotions are bad or inappropriate and I shouldn t feel them. 31. I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow. 32. My natural tendency is to put my experiences into words. 33. When I have distressing thoughts or images, I just notice them and let them go. 34. I do jobs or tasks automatically without being aware of what I m doing. 35. When I have distressing thoughts or images, I judge myself as good or bad, depending what the thought/image is about. 36. I pay attention to how my emotions affect my thoughts and behavior. 37. I can usually describe how I feel at the moment in considerable detail. 38. I find myself doing things without paying attention. 39. I disapprove of myself when I have irrational ideas.