Screening Tool Topic E. Community and Lifestyle

Patient Details

Patient Name:

Patient ID:


Quiz

🎯Topic E. Community and Lifestyle

E1. Supportive Network

Do you have friends or people you can rely on for support?

🎯Topic E. Community and Lifestyle

E2. Frequency of Feeling Lonely

How often do you feel lonely?

🎯Topic E. Community and Lifestyle

E3. Exchange of Visits

Do you engage in visits or receive visitors often, sometimes or never / rarely?

🎯Topic E. Community and Lifestyle

E4. Alcohol Consumption

How often do you consume alcohol? Would you say never, occasionally, or regularly?

Topic E. Community and Lifestyle

E5. Tobacco Use

Do you use tobacco? If so, do you currently use it, have you used it formerly, or never?

🎯Topic E. Community and Lifestyle

E6. Illicit Drug Use

Have you used illicit drugs? If so, do you currently use them, have you used them formerly, or never?

🎯Topic E. Community and Lifestyle

E7. Engagement in Hobbies or Leisure Activities

How often do you engage in hobbies or leisure activities (singing, gardening, dancing, knitting, other)? Would you say regularly, occasionally, or rarely?

🎯Topic E. Community and Lifestyle

E8. Physical Exercise Routine

How would you describe your physical exercise routine (e.g., walking, running, swimming, gardening)? Is it light, moderate/high, or mostly sedentary?