Questionnaire
Date of Completion: ___________________________
Office/Workplace Name: ___________________________
Name: ___________________________
Please check the boxes that apply to you.
Question Item Response
1-3. Are you currently taking any of the following medications?
1. a. Medication to lower blood pressure Yes / No
2. b. Medication to lower blood sugar or insulin injections Yes / No
3. c. Medication to lower cholesterol or neutral fats (triglycerides) Yes / No
4. Has a doctor ever told you that you have had a stroke (e.g., cerebral
hemorrhage or cerebral infarction), or have you received treatment for Yes / No
it?
5. Has a doctor ever told you that you have heart disease (e.g., angina,
Yes / No
myocardial infarction), or have you received treatment for it?
6. Has a doctor ever told you that you have chronic renal failure, or are
Yes / No
you currently receiving treatment (e.g., dialysis)?
7. Has a doctor ever told you that you have anemia? Yes / No
8. Do you currently smoke habitually?
(A “habitual smoker” is someone who meets both of the following - Yes (meets both Condition 1 and 2)
conditions:) - Used to smoke but haven’t smoked in
- Condition 1: Have smoked in the past month the past month (only Condition 2 applies)
- Condition 2: Have smoked for more than 6 months in total or have - No (neither applies)
smoked 100 or more cigarettes in total
9. Has your weight increased by more than 10kg since you were 20
Yes / No
years old?
10. Do you engage in at least 30 minutes of light exercise that makes
Yes / No
you sweat, twice or more per week, for over one year?
11. Do you walk or perform equivalent physical activity for at least one
Yes / No
hour per day in your daily life?
12. Do you walk faster compared to people of the same age and
Yes / No
gender?
- Can chew anything
- Have concerns with teeth, gums, or bite
13. Which best describes your chewing condition when eating?
and sometimes find chewing difficult
- Can hardly chew
14. Do you eat faster compared to others? Fast / Normal / Slow
15. Do you eat dinner within two hours before going to bed, three or Yes / No
Question Item Response
more times per week?
- Every day
16. Do you eat snacks or drink sweet beverages other than during the
- Sometimes
three main meals (breakfast, lunch, dinner)?
- Rarely
17. Do you skip breakfast three or more times per week? Yes / No
- Everyday
- 5–6 days a week
18. How often do you drink alcohol (e.g., sake, shochu, beer, Western - 3–4 days a week
liquor)? - 1–2 days a week
("Quit drinking" refers to those who used to drink habitually at least once - 1–3 days a month
a month but have not consumed alcohol for over a year.) - Less than once a month
- Quit drinking
- Do not drink (cannot drink)
19. On days you drink, how much alcohol do you consume per day?
(1 "go" of sake (180ml, 15% alcohol) is approximately equivalent to:) - Less than 1 go
- Beer (5%, 500ml) - 1–2 go
- Shochu (25%, ~110ml) - 2–3 go
- Wine (14%, ~180ml) - 3–5 go
- Whiskey (43%, 60ml) - More than 5 go
- Canned chu-hi (5%, ~500ml or 7%, ~350ml)
20. Do you get enough rest from sleep? Yes / No
- Not planning to improve
- Planning to improve (within about 6
months)
- Planning to improve soon (within about
21. Are you thinking about improving your lifestyle habits (e.g.,
1 month) and have started a little
exercise, eating habits)?
- Already working on improvement (for
less than 6 months)
- Already working on improvement (for
more than 6 months)
22. Have you ever received Specified Health Guidance (tokutei hoken
Yes / No
shidō) regarding improving your lifestyle?