Page 131 - When surgery alone won’t cut it - Valerie Maureen Monpellier
P. 131

8. How much do you smoke?
 Very rarely
 Socially (less than 2 cigarettes per week)  less than 5 cigarettes per day
 5-10 cigarettes per day
 11-20 cigarettes per day
 21-40 cigarettes per day
 More than 40 cigarettes per day
9. Do you use drugs or have you used drugs (daily or weekly)?  Yes, but I have quite (go on to question number 10)
 Yes, I use ................................................
 No (go on to question number 11)
10. If you have quit, when did you quit? ...............................
11. Have you had a pregnancy in the last 12 months or do you want children in the near future?
 yes  No
12. Have you experienced major live-events, like a divorce or death of a close family member, in last 12 months?
 yes  No
13. Howfrequentlydoyouexercise?
 Not at all (go on to question number 16)  Once per month or less
 Several times per month
 Once per week
 Several times per week
 Once per day
 Several times a day
14. If you exercise, how long do you exercise each time?  Less than 15 minutes
 15-30 minutes
 31-60 minutes
 61-120 minutes
 More than 120 minutes
15. Where do you do most of your exercise?  Inside
 Outside
16. If you exercise, please indicate the types of exercise you do (fill in all that apply):
145
Cycling
             Stationary bike
           Swimming
           Stairmaster
           Zumba
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