知己健康管理健康信息调查表（Health information questionnaire for confidant health management）

知己健康管理健康信息调查表（Health information questionnaire for confidant health management） 知己健康管理健康信息调查表(Health information questionnaire for confidant health management) Intimate health management health information questionnaire I. Basic Conditions 1. name, ID number 2. sex, mouth, male, female 3. date of birth The 4. national export of Hankou Zhuang mouth mouthful of other 5. marital status unmarried married Yikou mouth mouth mouth mouth from the other spouse 6. literacy, oral illiteracy, primary school, junior high school, high school and technical secondary school, bachelor's degree or above 7. professional cadres, medical and health professionals, teachers, scientific and technical personnel, financial staff, financial personnel Mouth worker population, farmer mouth, unemployed mouth, retirement mouth, household affairs, etc. 8. address 9. telephone number Two. Current health status 1. generally speaking, your health condition is: the mouth is very good, the mouth is good, the mouth is general, the mouth is bad 2., you feel tired for some time: mouth fatigue, mouth a little tired, mouth tired, mouth very tired 3. compared with the same year ago, your weight is: mouth increase, mouth basic unchanged, mouth drops, mouth is not clear 4. have you tried to lose weight in nearly a year? Mouth is mouth 5. have you had any blood pressure in the past half a year? The mouth has not been measured and the mouth has been measured 6. have you tested blood lipid in the past half year? The mouth has not been measured and the mouth has been measured 7. how often have neck, waist, hip joint pain: - is not. 8. have chronic diarrhea, constipation, stool is not normal: - - is not 9. chronic lifestyle diseases Mouth hypertension, coronary heart disease, oral diabetes mellitus, dyslipidemia, and stroke Oral fatty liver, mouth fat, mouth pain, tuyere, lower limb artery occlusion, polycystic ovary syndrome 10. family history; diabetes mellitus; hypertension; hyperlipidemia; coronary heart disease; stroke; obesity; lower extremity arterial occlusion; metabolic syndrome (MS) Father's mouth, mouth, mouth, mouth, mouth, mouth Mother's mouth, mouth, mouth, mouth, mouth, mouth Three diet and exercise 1. dietary patterns The 1.1 day: the main non-staple food proportion in staple food mainly export the main non-staple food staple export export were supplemented by main non-staple food 1.2, tofu and soy products intake: mouth every day to eat, mouth often eat, occasionally eat mouth do not eat 1.3, milk and dairy products intake: mouth every day to eat, mouth often eat, occasionally eat mouth do not eat Eat vegetables every day: 1.4 of the average export more than 8 two two 2-4 two 5-7 < 2 two Eat 1.5 fruits per day: two 3-4 two more than 5 export export export less than 2 in two do not eat Eat egg 1.6 daily average of more than 3 export: export 2 port 1 port 1. Eat fish and meat: the daily average of 1.7 export more than 8 two 5-7 two 2-4 two = 1 two 1.8 per person per month vegetable oil consumption: mouth > 4 jin, mouth 3-4 Jin, mouth 2-3 jins, mouth less than 2 jin 1.9 per person per month for salt consumption: export more than 8 two 6-7 two 4-5 two < 4 two 1.10 do you often have breakfast? Mouth to eat every day, often mouth, occasionally eat mouth do not eat 1.11 how many meals do you usually have a day? Two mouth, five mouth, four mouth, more than two meals 2. physical activity and exercise 2.1 the sitting time of work or daily life (8 hours): Mouth almost all mouth more than 4 hours, mouth less than 4 hours, almost no 2.2, close distance (within 3 kilometers) to go out to work, your main way of travel is: Mouth, walk, bicycle, mouth, car or drive, seldom go out to work 2.3 in general, how long does it take you to commute? In less than 10 port 11-30 port 31-60 > 60 2.4 daily life of mopping the floor, cleaning windows and other household chores: mouth often mouth, sometimes mouth little, mouth no 2.5 do you exercise? - is not. 2.6 if you take part, your most frequently used method of exercise is (only one of the most popular): Mouth, walk, mouth, running, mouth, bicycle, mouth, dance or Taijiquan Mouth, stair, mouth, ball, mouth, swimming pool, etc. 2.7 how many times do you exercise every week? Export less than or equal to 2 times 3-4 times more than 5 times in the mouth 2.8 how many minutes is the average workout time? In less than 20 port 21-40 port 41-60 > 60 Four, behavior habits 1. smoking 1.1 do you have passive smoking? Mouth often mouth occasionally mouth little, never from mouth 1.2 whether smoking: mouth, mouth is mouth, even mouth, already quit 1.3 daily smoking counts: 1-5 mouth, 6-10 mouth, 11-20 mouth, 20 mouth 1.4 years of smoking: mouth 1 years, mouth 1-5 years, 6-10 years, more than 11 years 2. drinking 2.1 do you drink regularly: mouth, mouth, mouth, and mouth 2.2 main types: white wine drinking beer and wine in the other 2.3 daily average alcohol intake ml/ days 3. mental and sleep 3.1 have you been energetic in the past month? Most of the time mouth, more time, a small mouth, part of the mouth does not feel this way 3.2 have you lived a full life in the past month? Most of the time mouth, more time, a small mouth, part of the mouth does not feel this way 3.3 you feel dejected, nothing can cheer you up? Mouth is mouth 3.4 sleep condition: mouth is bad, mouth is bad, mouth is general, mouth is good 3.5 sleep time: mouth < 6 hours, mouth 6-8 hours, 9-10 hours > 10 hours 3.6 do you often stay up late? Mouth often mouth occasionally mouth little mouth no Five. Physical examination 1. general inspection Height (CM) Weight (kg) Waist circumference (CM) Blood pressure (mmHg) 2. laboratory tests Total cholesterol (mmol/L) Triglyceride (mmol/L) High density lipoprotein (mmol/L) Low density lipoprotein (mmol/L) Fasting plasma glucose (mmol/L) 2 hours postprandial blood sugar (mmol/L) Glycated hemoglobin (%) 3. other checks B ultrasound fatty liver: mouth without mouth, mild mouth, moderate severe mouth Record date One