1) Gender
□ Female
2) Age _____________
□ Male
3) What is your educational degree?
Any degree / post-graduate
High school diploma
Less than high school diploma
4) Which is your current job?
Employed
Student
Unemployed
□
□
□
□
□
□
5) Has your doctor ever told you that you suffer from one or more of the following diseases?
No
I’ve suffered
from it in the
past
□
□
Diabetes
□
□
High blood pressure
□
□
Myocardial infarction or other cardiovascular diseases
□
□
Stroke or other cerebrovascular diseases
□
□
Other heart diseases (arrythmia, valvulopathy, other
myocardiopathies)
□
□
Chronic kidney disease
□
□
Hypercholesterolemia
□
□
Obesity
□
□
Thyroid diseases
□
□
Cancer (lymphoma or leukaemia included)
□
□
Depression, anxiety
□
□
Gastroenteric diseases
□
□
Respiratory diseases
□
□
Diseases of the nervous system
□
□
Genitourinary disorders
□
□
Rheumatic/Autoimmune diseases
6) Have you ever been told that …?
□ You were born preterm
□ You were born overweight (more than 4 kg)
I currently
suffer from it
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□ You were born underweight (2.4 kg or less)
□ You were born normoweight and on term
7) Did you regularly take drugs or supplements during the last month?
□ YES
□ NO
if yes which one? _____________________________________________
8) Think about your last 12 months. How often, on average, have you eaten your main meals (breakfast, lunch
dinner) in the following places? (Mark a single option for each row)
Never
a) Restaurant/canteen
b) Fast-food
c) Cafe, Pizza place
d) Street food
□
□
□
□
1-3 times per
month
□
□
□
□
9) How often do you add salt to your food?
10) How much bread do you eat in a full day?
□ 4-5 slices or 4-5 small rolls
1-2 times per
week
□
□
□
□
□ never or rarely
Once a day
□
□
□
□
More than once
a day
□
□
□
□
□ quite often □ always or very often
□ 3 slices or 3 small rolls or less
□ more than 5 slices or 5 small rolls
1
11) How many times per week do you eat cheese, ham, salami, sausages?
□ 0-2 times
□ 3-4 times
□ 5 or more times
12) How often do you feel thirsty, especially after a meal?
□ never or rarely
□ quite often
□ always or very often
13) When you eat out, does the food usually seems … □ insipid
□ YES
14) Do you use a laptop or tablet?
□ salty
□ 1-2 hours
□ 3-5 hours
□ NO
15) If you use a laptop or tablet, how many hours per day?
5 hours
16) Do you feel that your use of the laptop or tablet is?
□ normal
□ eccessive
□ moderate
□ more than
□ scarce
17) In the past 12 months, during a typical day, how many alcoholic drinks have you assumed?
Alcoholic drinks are one glass of wine (nearly 15 cl), one bottle/can of beer (33 cl), one shot of liquor (5 cl) or a cocktail
□ 0 drink
□ 1-2 drinks
□ 3-4 drinks
□ 5-6 drinks
□ 7-9 drink s
□ 10 or more drinks
□ YES
18) Did you ever think your alcohol consumption is excessive?
19) Do you smoke?
□ YES
□ NO
□ NO
□ I quitted
20) If you smoke, how many cigarettes per day?
>40
□<5
□ 5-20
□ 21-40
□
21) If you don’t smoke, are you exposed to passive smoking (for instance at work or at home)? □ YES
22) Do you regularly practice physical activity?
□ YES
□ NO
□ NO
23) If you practice physical activity, how many times per week?
□
All days
□
Some days (indicate the number_____)
□
Never
24) Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the
statement applied to you over the past week. There are no right or wrong answers. Do not
spend too much time on any statement.
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of time
3 Applied to me very much, or most of the time
1
I found it hard to wind down
0
1
2
3
2
I was aware of dryness of my mouth
0
1
2
3
3
I couldn't seem to experience any positive feeling at all
0
1
2
3
4
I experienced breathing difficulty (eg, excessively rapid breathing,
breathlessness in the absence of physical exertion)
0
1
2
3
5
I found it difficult to work up the initiative to do things
0
1
2
3
6
I tended to over-react to situations
0
1
2
3
7
I experienced trembling (eg, in the hands)
0
1
2
3
8
I felt that I was using a lot of nervous energy
0
1
2
3
2
9
I was worried about situations in which I might panic and make
a fool of myself
0
1
2
3
10
I felt that I had nothing to look forward to
0
1
2
3
11
I found myself getting agitated
0
1
2
3
12
I found it difficult to relax
0
1
2
3
13
I felt down-hearted and blue
0
1
2
3
14
I was intolerant of anything that kept me from getting on with
what I was doing
0
1
2
3
15
I felt I was close to panic
0
1
2
3
16
I was unable to become enthusiastic about anything
0
1
2
3
17
I felt I wasn't worth much as a person
0
1
2
3
18
I felt that I was rather touchy
0
1
2
3
19
I was aware of the action of my heart in the absence of physical
exertion (eg, sense of heart rate increase, heart missing a beat)
0
1
2
3
20
I felt scared without any good reason
0
1
2
3
21
I felt that life was meaningless
0
1
2
3
25) How many hours per night do you usually sleep?
□ ≤ 5 hours
□ 6 hours
□ 7 hours
□ ≥ 8 hours
26) Please rate the current (i.e. in the last month) severity of your insomnia problems.
No
Mild
Moderate
Severe
□
□
□
□
Difficulty falling asleep
□
□
□
□
Difficulty staying asleep
□
□
□
□
Problem waking up too early
27) How satisfied/dissatisfied are you with your current sleep pattern?
□ Very satisfied □ Satisfied
□ Moderately dissatisfied □ Dissatisfied
Very severe
□
□
□
□ Very dissatisfied
28) Do you Snore Loudly (loud enough to be heard through closed doors)? □ YES □ NO
28) Has anyone observed you stop breathing during your sleep ? □ YES
□ NO
3