Health Inequalities Survey 1) What is your age? OptionalPlease Select…16 – 2526 – 3435 – 4445 – 5455 – 6465 – 74Over 752) What is your sex? OptionalPlease Select…MaleFemalePrefer not to say3) How worried are you about your weight? OptionalPlease Select…Not at allSomewhatNot at all4) What things have been helpful to you in the past when you lost weight? Optional 5) How would you describe your current eating habits? OptionalPlease Select…HealthySomewhat HealthyUnhealthy6) What is your motivation level to lose weight? OptionalPlease Select…Not at allSomewhatA great deal7) What activities have you engaged with in the past to help you lose weight? (tick all that apply) Slimming World Optional Weight watchers Optional NHS digital weight management (Referred by Clinician) Optional Gym pass Optional Medications Optional Surgery Optional Followed diet books Optional Internet advice Optional Other Optional Please Specify 8) What are the barriers to you losing weight? (tick all that apply) Child care/Time Optional Mixed messaging about healthy food and drink Optional The cost of healthy food Optional Lack of time for meal planning / cooking / physical activity Optional Unhealthy work environment Optional Poor access to exercise facilities Optional Emotional issues around eating Optional Lack of support Optional Lack of support from health services Optional Low mood/mental health problems Optional Physical health problems/medications Optional Other Optional Please Specify 9) What type of support do you need to help you lose weight? (tick all that apply) Education Optional Time Optional Psychological support Optional Gym Optional Medical Optional Other Optional Please Specify 10) In the past week, how many days have you done 30 minutes or more of physical activity, which was enough to raise your breathing? OptionalPlease Select…0 Days1 Day2 Days3 Days4 Days5 Days6 Days7+ DaysThis may vary from sport, cycling and brisk walking, but should not include housework.On behalf of Cleveleys Group Practice, Thornton Practice and Crescent Surgery, we would like to thank you for taking the time to fill in this survey.
