Tobacco consumption

12

Do you currently smoke tobacco products such as cigarettes, cigars or pipes?

Yes 1

No 2

13

If yes, do you smoke daily?

Yes 1

No 2

14

How much of the following do you smoke on average each day?

Industrial Cigarettes |__|__|__|

Rolled Cigarettes |__|__|__|

Pipes |__|__|__|

Cigars, cigarillos |__|__|__|

Other |__|__|__|

15

In the past, have you ever used tobacco daily?

Yes 1

No 2

Alcohol consumption

16

Have you consumed an alcoholic beverage such as beer, wine, liquor, cider, or local liquor in the past 12 months?

If Yes,

USE THE CARDS ORSHOW EXAMPLES

Yes 1

No 2

17

During the past 12 months, how often did you drink at least one alcoholic beverage?

Daily 1

5 - 6 days per week 2

1 - 4 days per week 3

1 - 3 days per month 4

Less than once per month 5

18

When you drink alcohol, how many drinks do you have on average per day?

Number |__|__|

Don’t know 0

Physical activity

19

Does your job involve high-intensity physical activities that require a substantial increase in breathing or heart rate, such as [heavy lifting, working on a construction site, doing masonry work] for at least 10 minutes at a time?

Yes 1

No 2

20

On a typical day during which you perform high-intensity physical activities, how much time do you spend on these activities?

………………….

21

Does your job involve moderate intensity physical activity, such as brisk walking or [light lifting] for at least 10 minutes at a time?

Yes 1

No 2

22

Do you make trips of at least 10 minutes on foot or by bicycle?

Yes 1

No 2

23

Do you participate in any high-intensity sports, fitness, or recreational activities that require a significant increase in breathing or heart rate such as [running or playing soccer] for at least ten minutes at a time?

Yes 1

No 2

24

On a typical day, how much time do you spend on it?

……….......

History of diabetes