Formic Online Forms - [Healthy Lifetyles Survey V2

Healthy Lifestyles Clinic Online Survey

Thank you for participating in this anonymous survey, we value every opinion. Please answer the questions below as honest as you can, we will not judge you, we only will learn from your life experience which we know is very challenging at times. We would like to learn your lifestyle behaviours prior to coming to MS Healthy Lifestyle clinic (HLS) group clinic. We wish to reassess you again in a years time following the healthy lifestyle group clinic today.

Duration of your MS disease:

What type of MS do you have?

Are you:

Male

Female

Date of attendance
(this is a mandatory field, please complete before you can continue)

/

Please tell us your height:

Please tell us your weight:

Diet

Did you add sugar to your hot drinks?

Yes

No

N/A

If yes, how many teaspoons?

How many hot drinks did you have a day?

Did you drink energy drinks or soft drinks?

Yes

No

If yes, how many would you drink a day?

How many times a week would you eat confectionary, biscuits, cakes or chocolate?

How many times a week would you eat red meat?

How many times a week would you eat chicken?

How many times a week would you eat Fish?