Lifestyle-Related Disease Questionnaire
A Gender? male ・ female
B Age group? Teens 20’s 30’s 40’s 50’s Over 60
About to lose your weight
1. Have you ever tried to lose your weight?
a) Yes →please go to Q.2 & Q.4 b) No
1. Have you ever tried to lose your weight?
a) Yes →please go to Q.2 & Q.4 b) No
2. If you answered a) in Question 1, what was your purpose?
(You can choose multiple answers.)
a) To keep my health. b) To stay in shape. c) To recover my health.
d) To improve results of the physical checkup. →please go to Q.5
e) Other answers. ( )
(You can choose multiple answers.)
a) To keep my health. b) To stay in shape. c) To recover my health.
d) To improve results of the physical checkup. →please go to Q.5
e) Other answers. ( )
3. If you answered a) in Question 1, what way did you try to lose your weight?
(You can choose multiple answers.)
a) Putting on a diet. b) Taking physical exercises. c) Taking supplements
d) Taking slimming medicines. e) Taking a surgical operation.
f) Other answers. ( )
(You can choose multiple answers.)
a) Putting on a diet. b) Taking physical exercises. c) Taking supplements
d) Taking slimming medicines. e) Taking a surgical operation.
f) Other answers. ( )
4. If you answered d) in Question 2, what was the problem?
(You can choose multiple answers.)
a) Cholesterol value b) Blood pressure value c) Acylglycerol value d) Uric acid value
e) Blood sugar level
f) Other answers. ( )
(You can choose multiple answers.)
a) Cholesterol value b) Blood pressure value c) Acylglycerol value d) Uric acid value
e) Blood sugar level
f) Other answers. ( )
About the lifestyle-related disease
5. What significance do you take about preventing from lifestyle-related disease?
(You can choose three of them.)
a) Reducing alcohol. b) Giving up smoking. c) Taking exercise regularly. d) Stress-relieving
e) Reducing candies(sweets). f) Taking a lot of vegetables g) Cooking lightly-flavored meals.
h) Reduce sugar to use for cooking. i) Giving up eating between meals. j) Not eating fully.
k) Taking a physical checkup very often. l) Reducing oil ingredients
5. What significance do you take about preventing from lifestyle-related disease?
(You can choose three of them.)
a) Reducing alcohol. b) Giving up smoking. c) Taking exercise regularly. d) Stress-relieving
e) Reducing candies(sweets). f) Taking a lot of vegetables g) Cooking lightly-flavored meals.
h) Reduce sugar to use for cooking. i) Giving up eating between meals. j) Not eating fully.
k) Taking a physical checkup very often. l) Reducing oil ingredients
6. Recently “Metabolic Syndrome,” which significantly increases the risk of coronary heart disease, has
been well-known. What do you think the government should do to it?
a) The government should take measures soon from a viewpoint of keeping the nation’s health.
b) The government should take measures soon from a viewpoint of reducing medical expenses.
c) The government should keep a close watch on it now.
d) The government should not interfere in a private health problem of the nation.
e) Other answers. ( )
been well-known. What do you think the government should do to it?
a) The government should take measures soon from a viewpoint of keeping the nation’s health.
b) The government should take measures soon from a viewpoint of reducing medical expenses.
c) The government should keep a close watch on it now.
d) The government should not interfere in a private health problem of the nation.
e) Other answers. ( )
About the dietary life
7. Which meal do you take every day? Please choose all the things to apply to.
a) Breakfast b) Lunch c) Supper d) Dinner e) Snacks between meals. ( times)
f) Other answers. ( )
7. Which meal do you take every day? Please choose all the things to apply to.
a) Breakfast b) Lunch c) Supper d) Dinner e) Snacks between meals. ( times)
f) Other answers. ( )
Lifestyle-Related Disease Questionnaire
8. Please check (✓) the blanks which are fit to your eating habit.
| A specific example of the foods | Eat a lot | Eat ordinarily | Eat less | Eat nothing | |
| Staple foods | Rice, Bread, Noodle, Pasta etc | ||||
| Vegetables | Vegetable, Cereal, Mushroom etc | ||||
| Main dish | Meat, Fish, Egg, Soybean products etc | ||||
| Dairy products | Milk, Cheese, Yogurt | ||||
| Fruits | Apple, Orange etc | ||||
| Luxury goods | Sweets, Alcoholic drinks etc |
9. Which meal limit do you choose to prevent from obesity? (You can choose multiple answers.)
a) Caloric restriction b) Sugar free c) Salt free d) Fat free e) Addictive free
f) Other answers. ( )
a) Caloric restriction b) Sugar free c) Salt free d) Fat free e) Addictive free
f) Other answers. ( )
10. Which sweetener do you choose instead of sugar? (You can choose multiple answers.)
a) Oligos b) Honey c) Beet sugar d) Raw sugar e) Artificial sweetener
f) Other answers. ( )
a) Oligos b) Honey c) Beet sugar d) Raw sugar e) Artificial sweetener
f) Other answers. ( )
11.How often do you eat fast food?
a) Almost Everyday. b) A few times a week. C A few times a month.
d) A few times a year. e) I don’t have any fast food.
f) Other answers. ( )
a) Almost Everyday. b) A few times a week. C A few times a month.
d) A few times a year. e) I don’t have any fast food.
f) Other answers. ( )
About exercise
12. How often do you take a physical exercise a week?
a) Ones b) A few times. c) Almost everyday. →choose a),b) and c), please go to Q.13
d) I don't take any exercise.
e) Other answers. ( )
12. How often do you take a physical exercise a week?
a) Ones b) A few times. c) Almost everyday. →choose a),b) and c), please go to Q.13
d) I don't take any exercise.
e) Other answers. ( )
13. If you answered a), b) and c) in Question 12, what exercise do you take?
a) Walking b) Jogging c) Running d) Exercise directed by DVD.
e) Program of fitness center f) Machines for reducing weight g) Muscle enhancing
h) Other answers. ( )
a) Walking b) Jogging c) Running d) Exercise directed by DVD.
e) Program of fitness center f) Machines for reducing weight g) Muscle enhancing
h) Other answers. ( )
About a surgical weight loss method
14. What do you think about taking a surgical operation for losing your weight?
a) It should be admitted. b) It is not desirable. c) I should not be done. d) I don't know.
e) Other answers. ( )
14. What do you think about taking a surgical operation for losing your weight?
a) It should be admitted. b) It is not desirable. c) I should not be done. d) I don't know.
e) Other answers. ( )
Thank you for cooperation！
