CRISO T0 CRISO project. University of Malta. This questionnaire will take you about 10 minutes to complete. Question Title * 1. What is your identity number and your phone number? Question Title * 2. How did you get to know about the project? Poster method Video clip Referred by clinician Referred by patient Referred by a study participant Question Title * 3. When did your brother or sister or parent had their heart attack? Less than a month ago 1 month to 6 months ago More than 6 months ago Question Title * 4. What is your gender Male Female Other Question Title * 5. What is your age? 30-50 51-70 71+ Question Title * 6. What is your educational level Primary school Secondary school College/University Question Title * 7. Do you live by yourself? Yes No Question Title * 8. Are you employed? Yes No Question Title * 9. Do you smoke? Yes No Question Title * 10. If a smoker, how soon after you wake up do you smoke your first cigarette? Within 5 minutes 6-30 minutes 31-60 minutes After 60 minutes Question Title * 11. If a smoker, do you find it difficult to refrain from smoking in the places where it is forbidden (e.g., in church, at the library, in cinema)? Yes No Question Title * 12. If a smoker, which cigarette would you hate most to give up? The first one in the morning Any other Question Title * 13. If a smoker, how many cigarettes/day do you smoke? 10 or less 11-20 21-30 31+ Question Title * 14. If a smoker, do you smoke more frequently during the first hours after waking than during the rest of the day? Yes No Question Title * 15. If a smoker, do you smoke if you are so ill that you are in bed most of the day? Yes No Question Title * 16. Your physical activity status. Please check ONE answer that accurately describes you. I rarely or never do any physical activities I do some light (eg. walking leisurely, vacuuming) or moderate physical activities (eg. fast walking, swimming gently), but not every week I do some light physical activity every week I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week I do vigorous (eg. jogging, running) physical activities every week, but less than 20 minutes a day or 3 days a week I do 30 minutes or more a day of moderate physical activities, 5 or more days a week I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week Question Title * 17. I do activities to increase muscle strength (eg. lifting weights) once a week or more. Yes No Question Title * 18. I do activities to improve flexibility, such as stretching or yoga, once a week or more. Yes No Question Title * 19. The next questions are about your diet. Do you use olive oil as main culinary fat? Yes No Question Title * 20. How much olive oil do you consume in a given day? (Including oil used for frying, salads, out-of-house meals, etc.)? 4 tablespoons or more Less than 4 tablespoons Question Title * 21. How many vegetable servings do you consume per day? (1 serving: 200g -consider side dishes as half a serving) 2 vegetables or more Less than 2 Question Title * 22. How many fruit units (including natural fruit juices) do you consume per day? 3 or more fruits Less than 3 fruits Question Title * 23. How many servings of red meat, hamburger, or meat products (ham, sausage, etc.) do you consume per day? (1 serving: 100-150g) Less than 1 serving per day More than 1 serving per day Question Title * 24. How many servings of butter, margarine, or cream do you consume per day? (1 serving: 12g) Less than 1 serving per day More than 1 serving per day Question Title * 25. How many sweet or carbonated beverages do you drink per day? Less than 1 beverage per day More than 1 beverage per day Question Title * 26. How much wine do you drink per week? 7 or more glasses per week Not more than 7 glasses per week Question Title * 27. How many servings of legumes (eg. soy beans, kidney beans, fava beans) do you consume per week? (1 serving: 150g) 3 or more servings per week Less than 3 servings per week Question Title * 28. How many servings of fish or shellfish do you consume per week? (1 serving 100-150g of fish or 4-5 units or 200g of shellfish) 3 servings or more Less than 3 servings Question Title * 29. How many times per week do you consume commercial sweets or pastries (not homemade), such as cakes, cookies, biscuits, or custard? 3 or more servings per week Less than 3 servings per week Question Title * 30. How many servings of nuts (including peanuts) do you consume per week? (1 serving 30g) 3 or more servings per week Less than 3 servings per week Question Title * 31. Do you preferentially consume chicken, turkey, or rabbit meat instead of veal, pork, hamburger, or sausage? Yes No Question Title * 32. How many times per week do you consume vegetables, pasta, rice, or other dishes seasoned with tomato sauce, onion or garlic and simmered with olive oil? 2 times or more per week Less than 2 times per week Question Title * 33. The next questions are about your health literacy. How strongly you disagree or agree with the following statements: I have at least one healthcare provider who knows me well. Strongly disagree Disagree Agree Strongly agree Question Title * 34. I have at least one healthcare provider I can discuss my health problems with Strongly disagree Disagree Agree Strongly agree Question Title * 35. I have the healthcare providers I need to help me work out what I need to do Strongly disagree Disagree Agree Strongly agree Question Title * 36. I can rely on at least one healthcare provider Strongly disagree Disagree Agree Strongly agree Question Title * 37. I feel I have good information about my 'heart' health Strongly disagree Disagree Agree Strongly agree Question Title * 38. I have enough information to help me deal with my health problems Strongly disagree Disagree Agree Strongly agree Question Title * 39. I am sure I have all the information I need to manage my 'heart' health effectively Strongly disagree Disagree Agree Strongly agree Question Title * 40. I have all the information I need to look after my 'heart' health Strongly disagree Disagree Agree Strongly agree Question Title * 41. I spend quite a lot of time actively managing my 'heart' health Strongly disagree Disagree Agree Strongly agree Question Title * 42. I make plans for what I need to do to be healthy Strongly disagree Disagree Agree Strongly agree Question Title * 43. Despite other things in my life, I make time to be healthy Strongly disagree Disagree Agree Strongly agree Question Title * 44. I set my own goals about health and fitness Strongly disagree Disagree Agree Strongly agree Question Title * 45. There are things that I do regularly to make myself healthier Strongly disagree Disagree Agree Strongly agree Question Title * 46. I am on the following drug treatment:Drug to control blood pressure Yes No Question Title * 47. Drug to control cholesterol Yes No Question Title * 48. Drug to control blood glucose Yes No Question Title * 49. You wish to be contacted by the researcher to schedule an appointment. Yes No Done
