Timestamp you can calculate with:
Today Y-M-D
Please choose which language you would like use for this survey.
请选择此项问卷的语言:
* must provide value
English 英文
Chinese 中文
Your location:
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Auckland
Wellington
你的所在地:
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Auckland 奥克兰
Wellington 惠灵顿
Pre-screening data may be used to assess the feasibility of the study; to determine/understand reasons why some individuals may not be eligible to participate in the intervention. This information will be de-identified for analysis purposes. Please select if you wish to have your data used for these feasibility analyses (choose Yes or No).
* must provide value
Yes
No
预筛选数据将会被用于评估研究的可行性;以确定/了解为什么有些人可能没有达到参加此干预研究的标准。这些信息将被去个人信息化,以用于分析目的。
请选择你是否希望将你的数据用于这些可行性分析(请在框中打勾):
* must provide value
我愿意将我的数据用于此项可行性分析
我不希望我的数据用于此项可行性分析
a Last name:
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a
First name:
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b Gender:
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Male
Female
Please select your gender first to complete the following questions.
b 男性
女性
请先选择你的性别以便回答接下来的问题。
c The ethnic background of your father is:
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Mainland Chinese
Singaporean
Malaysian
Hong Kong Chinese
Taiwan Chinese
Chinese living in other countries
Other
Both parents have to be Chinese ethnicity to enter this study.
c 你的父亲的族裔:
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中国大陆华人
新加坡华人
马来西亚华人
香港华人
台湾华人
住在其他地区的华人
其他
Please specify your father's ethnic group.
请写下你的父亲的族裔:
* must provide value
d The ethnic background of your mother:
* must provide value
Mainland Chinese
Singaporean
Malaysian
Hong Kong Chinese
Taiwan Chinese
Chinese living in other countries
Other
Both parents have to be Chinese ethnicity to enter this study.
d 你的母亲的族裔:
* must provide value
中国大陆华人
新加坡华人
马来西亚华人
香港华人
台湾华人
住在其他地区的华人
其他
Please specify your mother's ethnic group.
* must provide value
请写下你的母亲的族裔:
* must provide value
e Address:
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Please provide a valid physical address for us to contact you in the future.
e
f Contact telephone number (landline):
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If you don't have a landline, please enter None.
f 联系电话(地线):
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g Contact mobile number:
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Please provide a valid mobile number for us to contact you.
g 手机电话:
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h E-mail address:
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Please provide a valid e-mail address for us to contact you.
h 电子邮箱:
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1 Date of birth:
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Today Y-M-D Please provide your date of birth first to complete the following questions.
1
Today Y-M-D 请先输入你的生日以便完成下面的问题。
2 View equation
2 View equation
View equation
3 Body weight (kg):
* must provide value
For example: If you weight 60 kg, enter 60
3 体重(公斤):
* must provide value
例子: 如果你的体重是60公斤(120斤),输入60
4 Height (m):
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For example: If you are 1.60 meter tall, enter 1.60
4 身高(m):
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例子:如果你的身高是1米60,输入1.60
5 View equation
5 View equation
View equation
6 Waist circumference (cm):
* must provide value
For example: If your waist circumference is 100 cm, please enter 100
6 腰围(厘米):
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例子:如果你的腰围是100厘米, 输入100
Waist circumference range score:
View equation
7 Do you usually have daily at least 30 minutes of physical activity at work or during leisure time (including normal daily activity)?
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Yes
No
Please choose one.
7 你是否平时在工作或休闲时间每日做至少30分钟的活动(包括正常的日常活动)?
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是
否
Please choose one.
8 How often do you eat vegetables, fruits or berries?
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Everyday
Not everyday
8 你多久吃一次蔬菜,水果或浆果?
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每天
不是每天
9 Have you ever taken medication for high blood pressure on the regular basis?
* must provide value
No
Yes
9 你有没有经常服用高血压药物?
* must provide value
没有
有
10 Have you ever been found to have high blood glucose (eg in a health examination, during an illness, during pregnancy)?
* must provide value
No
Yes
10 你有没有曾经发现有高血糖(例如,在健康检查,生病期间,怀孕期间)?
* must provide value
没有
有
11 Have any of the members of your immediate family or other relatives been diagnosed with diabetes (type 1 or type 2)?
* must provide value
No
Yes: grandparent, aunt, uncle or first cousin (but no own parent, brother, sister or child)
Yes: parent, brother, sister or own child
If your parent(s) and/or other family members have diabetes, please choose "Yes: parent, brother, sister or own child".
11 你的直系亲属或其他任何家族成员是否被诊断患有糖尿病(1型或2型)?
* must provide value
没有
有: 祖父母, 阿姨/姑姑, 叔叔/伯伯或者表亲 (但是你自己父母,亲兄弟姐妹或子女中没有糖尿病患者)
有: 父母, 亲兄弟姐妹, 或者子女
View equation
1 Are you in good general health?
* must provide value
Yes
No
1 你是否健康?
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是
否
2 Do you have diabetes?
* must provide value
Yes
No
2 你有糖尿病吗?
* must provide value
是
否
3 Do you have any other major health problems?
* must provide value
Yes
No
3 你有其他主要的健康问题吗?
* must provide value
是
否
If so, what are these?
* must provide value
如果有,是那些问题?
* must provide value
4 Do you have heart disease (previous angina, heart attack, or stroke)?
* must provide value
Yes
No
4 你是否有心脏疾病(曾经发生过心绞痛,心脏病发作或中风)?
* must provide value
是
否
If so, what is the disease
* must provide value
如果有,是哪些疾病?
* must provide value
5 Do you have kidney disease?
* must provide value
Yes
No
5 你是否有肾脏疾病?
* must provide value
是
否
If so, what is the disease
* must provide value
如果有,是哪些疾病?
* must provide value
6 Have you had cancer (other than skin cancer)?
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Yes
No
6 你是否有过癌症(除了皮肤癌以外)?
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是
否
If so, which cancer and when
* must provide value
如果有,是那种癌症,什么时候患次疾病
* must provide value
7 Do you have a gastrointestinal and/or stomach disease (e.g. Crohn's, IBD)?
* must provide value
Yes
No
7 你是否有消化道和/或者胃部疾病(比如,克罗恩病,炎症性肠病)?
* must provide value
是
否
If so, what is the disease
* must provide value
如果有,是什么疾病?
* must provide value
8 Do you have a respiratory (lung) disease?
* must provide value
Yes
No
8 你是否有呼吸道疾病(肺病)?
* must provide value
是
否
If so, what is the disease
* must provide value
如果有,是什么疾病?
* must provide value
9 Do you have a neurological or musculoskeletal disease or mobility problem?
* must provide value
Yes
No
9 你有神经或肌肉骨骼疾病或行动不便问题吗?
* must provide value
是
否
If so, what is the disease
* must provide value
如果有,是什么疾病?
* must provide value
10 Do you have hepatitis B/C or HIV? (Transmissible blood-borne diseases)?
* must provide value
Yes
No
10 你是否有乙肝或丙肝或艾滋病(传染性血源性疾病)?
* must provide value
是
否
11 Have you been diagnosed with major depression, bipolar disease, or other severe mental illness?
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Yes
No
11 你是否被诊断为重性抑郁症,双相情感障碍或其他严重精神疾病?
* must provide value
是
否
If so, which condition
* must provide value
如果有,是什么疾病?
* must provide value
12 Do you have a major food allergy?
* must provide value
Yes
No
12 你有严重的食物过敏吗?
* must provide value
是
否
If so, what are you allergic to?
* must provide value
如果有,你对什么食物过敏?
* must provide value
13 Have you had any major surgery, including weight loss (bariatric) surgery?
* must provide value
Yes
No
13 你有过任何大手术,包括减肥手术吗?
* must provide value
是
否
If so, which surgery and when
* must provide value
如果有,是什么手术,在什么时候进行的?
* must provide value
14 Have you ever been diagnosed with the significant liver disease (e.g. hepatitis, cirrhosis - fatty liver ok) ?
* must provide value
Yes
No
14 你有没有被诊断出患有显着的肝脏疾病(例如肝炎,肝硬化 - 脂肪肝不包括在内)?
* must provide value
是
否
If so, what is the disease
* must provide value
如果是,是什么疾病
* must provide value
15 Have you ever been diagnosed for high blood pressure? (Systolic BP > 160mmHg, diastolic BP > 100mmHg)
* must provide value
Yes
No
15 你有没有被诊断为高血压? (收缩压> 160mmHg,舒张压> 100mmHg)
* must provide value
是
否
Are you currently taking any prescribed medication?
* must provide value
I am not taking any medication
I am currently taking prescribed medication.
16 What is prescribed medication you are currently taking?
* must provide value
Details of medication (name and dose) for diabetes:
* must provide value
Details of medication (name and dose) for weight loss:
* must provide value
Details of medication (name and dose) for high blood pressure:
* must provide value
Details of medication (name and dose) for depression:
* must provide value
Details of medication (name and dose) for any other conditions:
* must provide value
Details of herbal medication (name and dose):
* must provide value
你正在服用任何处方药吗?
* must provide value
目前我没有服用任何处方药物
我正在服用处方药
16 你正在服用什么处方药?
* must provide value
糖尿病药物用药细节(名称和剂量):
* must provide value
减肥药物用药细节(名称和剂量):
* must provide value
高血压药物用药细节(名称和剂量):
* must provide value
抗抑郁药物用药细节(名称和剂量):
* must provide value
其他疾病用药细节(名称和剂量):
* must provide value
中药草药用药细节(名称和剂量):
* must provide value
1 Are you a professional sports person, or in competitive sports?
* must provide value
Yes
No
1 你是职业运动员还是竞技运动员?
* must provide value
是
否
2 Has your weight changed by more the 5kg in the last 2 months?
* must provide value
Yes
No
2 在过去的2个月里,您的体重是否改变了5公斤(增加或减少)?
* must provide value
是
否
3 Are you currently on a specific weight loss diet (Eg Atkins diet, Paleo)?
* must provide value
Yes
No
3 你目前是否在进行特定的减肥饮食项目(例如阿特金斯饮食,Paleo)?
* must provide value
是
否
4 Are you a vegan (no eggs, no meat, no fish, no dairy), or have been
within the last 2 months?
* must provide value
Yes
No
4 你是纯素食者(没有鸡蛋,没有肉,没有鱼,没有乳制品),或者在过去的2个月内进行纯素食饮食?
* must provide value
是
否
5 Do you regularly drink more than 21 regular alcoholic drinks per week?
(1 regular alcoholic drink = 1 small glass of wine 120ml / 1 bottle of beer 330ml/ 1 shot of spirits 30ml)
* must provide value
Yes
No
5 您是否经常每周饮用超过21单位普通酒精饮料
(1单位普通酒精= 1杯小酒120ml / 1瓶啤酒330ml / 1杯烈酒30ml)
* must provide value
是
否
5 Do you regularly drink more than 14 regular alcoholic drinks per week?
(1 regular alcoholic drink = 1 small glass of wine 120ml / 1 bottle of beer 330ml/ 1 shot of spirits 30ml)
* must provide value
Yes
No
5 您是否经常每周饮用超过14单位普通酒精饮料?
(1普通酒精单位= 1杯小酒120ml / 1瓶啤酒330ml / 1杯烈酒30ml)
* must provide value
是
否
If so, what type and how many?
* must provide value
If so, how many drinks per week?
* must provide value
E.g. 1 regular alcoholic drink = 1 small glass of wine 120ml or 1 bottle of beer 330 ml or 1 shot of spirits 30 ml.
If so, what type?
* must provide value
If so, how many drinks per week?
* must provide value
E.g. 1 regular alcoholic drink = 1 small glass of wine 120ml or 1 bottle of beer 330 ml or 1 shot of spirits 30 ml.
如果是,那几种酒精饮料?
* must provide value
如果是,每周喝几个酒精单位?
* must provide value
1普通酒精单位= 1杯小酒120ml / 1瓶啤酒330ml / 1杯烈酒30ml
如果是,那几种酒精饮料?
* must provide value
如果是,每周喝几个酒精单位?
* must provide value
1普通酒精单位= 1杯小酒120ml / 1瓶啤酒330ml / 1杯烈酒30ml
Are you taking any supplement?
* must provide value
Yes
No
你现在正在吃保健品吗?
* must provide value
是
不是
Please provide the name of all the supplements:
* must provide value
请列出你正在服用的所有保健品:
* must provide value
6 Have you used recreational drugs in the past 12 months?
* must provide value
Yes
No
6 您在过去12个月中使用过致幻药物吗?
* must provide value
是
否
7 Have you had a blood transfusion, or donated blood, in the past month?
* must provide value
Yes
No
7 过去一个月你是否有过输血或者献血?
* must provide value
是
否
8 Are you pregnant or breastfeeding?
* must provide value
Yes
No
8 你目前是否怀孕或者正在哺乳期间?
* must provide value
是
否
9 Do you have an eating disorder (anorexia, bulimia, etc)?
* must provide value
Yes
No
9 你有饮食失调(厌食症,贪食症等)吗?
* must provide value
是
否
If so, what is this?
* must provide value
如果有,是那个疾病?
* must provide value
Submit
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